Columbia  JBnibtvsit]^  ^^^^ 
in  tiie  Citp  of  iScttj  Horfe 

CoUese  of  Ij^fivsiciani  anb  ^urseonsc 


3^eference  i^itirarp 


POLIOMYELITIS 


IN  ALL  ITS  ASPECTS 


BY 


JOHN  RUHRAH,  M.D. 


PROFESSOR   OF    PEDIATRICS   IN   THE    UNIVERSITY    OF    MARYLAND    MEDICAL    SCHOOL    AND   THE 

COLLEGE    OF    PHYSICIANS    AND     SURGEONS;    CONSULTING    PEDIATRIST   TO    THE    BAYVIEW 

HOSPITAL    AND  TO  THE    CHURCH  HOME  AND    INFIRMARY;    VISITING    PEDIATRIST 

TO   THE  MERCY  HOSPITAL,  THE  HOSPITAL  FOR  THE  WOMEN  OF  MARYLAND, 

ROBERT  GARRETT  HOSPITAL  FOR  CHILDREN,  NURSERY    AND 

child's    HOSPITAL,    AND    TO   THE    CHILDREN'S 

HOSPITAL  SCHOOL 


ERWIN  E.  MAYER,  M.D. 


FIRST    LIEUTENANT    IN    THE    MEDICAL    OFFICERS*     RESERVE    CORPS,     UNITED    STATES    ARMY; 
FORMER  SENIOR  RESIDENT  PHYSICIAN    AT  THE    MERCY    HOSPITAL;    INSTRUCTOR  OF 
MEDICINE  IN  THE  UNIVERSITY  OF  MARYLAND  MEDICAL  SCHOOL  AND 
COLLEGE    OF    PHYSICIANS    AND    SURGEONS 


ILLUSTRATED   WITH    118   ENGRAVINGS   AND  2    PLATES 


LEA    &    FEBIGER 

PHILADELPHIA  AND  NEW  YORK 

1917 


Copyright 

LEA   &   FEBIGER 

1917 


THIS  VOLUME  IS  INSCRIBED 
TO 

MISS  ANNA  MARIE  SCHIVE 

AND  TO 

MISS   ELIZABETH    M.    STONE 

SUPERINTENDENT   OF  THE   NURSERY   AND    CHILD 's   HOSPITAL   OF   BALTIMORE 

EST  APPRECIATION   OF 

THEIR   MANY    YEARS'    FAITHFUL    AND    EFFICIENT   SERVICE 

IN   THE    NURSING   AND    CARE    OF    SICK    CHILDREN 


X- 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Op#  Knowledge  Commons 


http://www.archive.org/details/poliomyelitisinaOOruhr 


PREFACE 


In  the  preparation  of  this  volume  the  authors  have  endeavored 
to  collect  the  various  facts  concerning  the  disease  as  far  as  they  are 
known  at  the  present  time  and  to  give  briefly  such  theoretic  consid- 
erations as  may  seem  to  be  either  of  interest  or  importance.  They 
have  attempted  to  gather  together  in  one  volume  the  information 
which  they  themselves  have  wanted  on  the  subject.  Ihe  literature 
of  poliomyelitis  has  grown  to  enormous  proportions  and  there  are 
over  three  thousand  articles  which  are  being  added  to  daily. 
Throughout  the  text  references  have  been  made  to  the  articles 
which  have  been  consulted,  but  no  extensive  bibliography  has  been 
added.  There  is,  at  present,  no  adequate  account  of  the  disease 
in  one  volume,  although  there  are  many  excellent  monographs 
featuring  one  or  more  phases  of  the  subject.  To  get  a  satisfactory 
account  of  the  disease  one  must  do  extensive  reading  which  requires 
not  only  time,  but  access  to  a  well-stored  library.  If  this  little 
volume  supplies  even  in  a  small  measure  what  seems  to  be  a  need, 
the  authors  will  be  amply  requited  for  their  labor  in  preparing  it. 

To  save  the  necessity  of  cross  reference  and  for  the  convenience 
of  those  who  may  wish  to  study  their  cases  carefully  tests  for  the 
examination  of  the  cerebrospinal  fluid  and  a  chapter  containing 
the  figures  and  tables  illustrating  the  various  facts  in  the  diagnosis 
and  localization  of  nervous  lesions  have  been  included. 

The  authors  have  many  aclmowledgments  to  make  and  wish  to 
express  their  thanks  to  all  who  have  helped  them.  First  of  all  the 
many  colleagues  whose  works  have  been  used.  They  have  endeav- 
ored to  indicate  in  every  instance  the  source  of  their  information. 
In  this  regard  they  are  particularly  obligated  to  ]\Iiss  W.  G.  Wright, 
whose  excellent  muscle  tests  and  exercises  in  Lovett's  monograi)h 
must,  of  necessity,  serve  as  a  model  for  all  who  attempt  to  tlescribc 
in  detail  these  two  important  features  in  the  treatment  of  the 


VI  PREFACE 

disease.  They  are  also  indebted  to  various  authors  for  illustra- 
tions and  to  Dr.  William  S.  Baer  and  Miss  Tabb,  of  the  Children's 
Hospital  School,  to  Dr.  Mathias  Nicoll,  Jr.,  of  the  New  York  State 
Department  of  Health,  for  others,  and  to  Mr.  Henry  Sharpies  for 
photographing  the  muscle  tests  and  exercises ;  to  the  Surgeon- 
General  of  the  United  States  Public  Health  Service,  the  officials 
of  the  Library  of  the  Surgeon-General  of  the  United  States  Army, 
the  Librarians  of  the  Medical  and  Chirurgical  Faculty  of  Maryland, 
the  Commissioners  of  Health  of  New  York  City,  and  particularly 
to  Dr.  Charles  Bolduan,  of  the  Department  of  Health  of  the  City 
of  New  York,  and  Dr.  Robert  W.  Lovett,  of  Boston,  for  many 
favors  and  to  Dr.  Albertus  Cotton,  for  suggestions  regarding  the 
chapters  on  orthopedic  and  surgical  treatment,  and  to  all  the  others 
who  have  generously  aided  in  the  work.  The  authors  are  especially 
indebted  to  Miss  Erna  Ball  for  the  work  which  she  has  done  on  the 
manuscript  and  for  preparing  the  index. 

J.  R., 
E.  E.  M. 

Baltimore,  July,  1917. 


CONTENTS. 


CHAPTER  I. 
History  of  Poliomyelitis 17 

CHAPTER  II. 

A  Conception  of  the  Disease 30 

CHAPTER  III. 
Pathology 32 

CHAPTER  IV. 
The  Nature  of  the  Virus 40 

CHAPTER   V. 
Epidemiology 52 

CHAPTER  VI. 
The  Synonyms  and  Classification 73 

CHAPTER  VII. 
Paralysis 93 

CHAPTER  VIII. 
Special  Features  and  Symptoms 122 

CHAPTER  IX. 

The  Technic  of  Lumbar  Puncture 135 


viii  CONTENTS 

CHAPTER  X. 
Diagnosis 144 

CHAPTER  XI. 
Prognosis 157 

CHAPTER  XII. 
Treatment 164 

CHAPTER  XIII. 
Orthopedic  Treatment '    .      .      .     .      .     185 

CHAPTER  XIV. 
Operative  Treatment 195 

CHAPTER  XV. 
Examination  of  Muscles  and  Muscle  Training     ......     204 

CHAPTER  XVI. 

The  Prevention  of  the  Disease 253 

CHAPTER  XVII. 
Bibliography 264 

CHAPTER  XVIII. 

Some  Anatomical  and  Physiological  Reminders 265 

CHAPTER  XIX. 
Epidemics 277 


POLIOMYELITIS. 


CHAPTER  I. 

HISTORY  OF  POLIOMYELITIS. 

Poliomyelitis  is  one  of  the  most  interesting  diseases  from  the 
standpoint  of  its  history,  inasmuch  as  it  seems  to  be  a  disease  of 
comparatively  recent  origin.  In  the  history  of  most  diseases  there 
is  a  gradual  shading  off  into  the  older  \\Titers  until  the  disease  is 
lost  in  confusion  of  inaccurate  descriptions,  but  with  poliomyelitis, 
as  with  whooping-cough,  the  disease  seems  to  have  originated  within 
comparatively  recent  times.  The  disease  is  so  striking  in  its  symp- 
tomatology, so  devastating  in  its  results,  and  produces  such  a  deep 
impression  on  the  popular  mind  that  it  does  not  seem  possible 
that  any  very  considerable  epidemics  could  have  happened  in  the 
countries  in  which  there  were  physicians  making  records  of  what 
occurred.  It  is  true  that  J.  K.  Mitchell  has  given  a  descripiton 
of  a  skeleton  of  an  Eg^'ptian  mummy  with  changes  which  were 
supposed  to  be  due  to  poliomyelitis.  Others  have  described  similar 
deformities  in  sculptured  objects  and  in  paintings;  but  such 
deformities,  we  must  acknowledge,  might  be  due  either  to  polio- 
myelitis or  to  other  lesions  of  the  nervous  system  occurring  in  early 
life. 

The  first  mention  of  the  disease  as  we  understand  it  today  seems 
to  have  been  by  Michael  Underwood  in  1784,  in  the  first  edition 
of  his  treatise  on  the  Diseases  of  Children.  L'nderwood  was  one  of 
the  first  licentiates  in  midwifery  of  the  Royal  College  of  Physicians 
of  London,  and  he  ^ecei^'ed  an  honorary  diploma  constituting  him 
a  doctor  of  medicine,  and  he  was  then  admitted  into  this  class  of 
licentiates,  together  with  other  distinguished  practitioners  of  mid- 
wifery in  London,  in  1784,  the  same  year  that  his  treatise  on  chil- 
dren was  first  published.    Underwood  was  a  skilful  accoucheur  and 

1  Tr.  Assn.  Am.  Phys.,  1900,  xv,  134. 


18  HISTORY  OF  POLIOMYELITIS 

received  great  popularity  from  having  attended  the  Princess  of 
Wales  in  the  year  1796,  when  the  Princess  Charlotte  was  born. 
He  will  live  in  the  history  of  medicine,  however,  on  account  of  the 
two  pages  that  he  devoted  to  a  condition  which  he  calls  "  the  debil- 
ity of  the  lower  extremities."  Underwood's  book  on  Diseases  of 
Children  was  deservedly  a  very  popular  one  and  went  through 
many  editions,  including  several  American  editions,  and  it  was 
translated  and  republished  many  times  in  Germany.  The  later 
editions  of  the  book  were  edited  by  either  Marshall  Hall  or  Samuel 
Merriman,  and  the  initialed  note  in  some  of  the  later  editions  as 
given  below,  shows  that  the  collaborators  did  not  always  tend  to 
improve  the  work.  The  most  important  part  of  Underwood's 
description  is  as  follows: 

"Debility  of  the  Lower  Extremities.— This  disorder  either  is  not 
noticed  by  any  medical  writer  within  the  compass  of  my  reading, 
or  is  not  so  described  as  to  ascertain  the  disease  here  intended.  It 
is  not  a  common  disorder  anywhere,  I  believe,  and  seems  to  occur 
seldomer  in  London  than  in  other  parts  of  the  kingdom.  Nor  am 
I  enough  acquainted  with  it  to  be  fully  satisfied,  either  in  regard 
to  the  true  cause,  or  seat  of  the  disease,  either  from  my  own  obser- 
vation, or  that  of  others,  with  whom  I  have  corresponded,  except 
in  the  instance  of  teething  or  of  foul  bowels;  and  I  have  not  myself 
had  an  opportunity  of  examining  the  body  of  any  child  who  has 
died  of  this  complaint.  I  shall  therefore  only  describe  its  symptoms, 
and  mention  the  several  means  attempted  for  its  cure  in  order  to 
induce  other  practitioners  to  pay  attention  to  it. 

"If  it  arises  from  teething,  or  foul  bowels,  the  usual  remedies 
should  be  employed;  and  have  always  effected  a  cure.  But  the 
complaint  as  often  seems  to  rise  from  debility,  and  usually  attacks 
children  previously  reduced  by  fever,  seldom  those  under  one  or 
more  than  four  or  five  years  old.  It  is  then  a  chronical  complaint, 
and  not  attended  with  any  affection  of  the  urinary  bladder,  nor 
with  pain,  fever,  or  any  manifest  disease;  so  that  the  first  thing 
observed  is  a  debility  of  the  lower  extremities,  which  gradually 
become  more  infirm,  and  after  a  few  weeks  are  unable  to  support 
the  body. 

"When  only  one  of  the  lower  extremities  has  been  affected  the 
above  means  in  two  instances  out  of  five  or  six  entirely  removed 
the  complaint;  but  when  both  have  been  paralytic,  nothing  has 
seemed  to  do  any  good  but  irons  to  the  legs,  for  the  support  of  the 
limbs,  and  enabling  the  patient  to  walk.     (It  may  be  doubted 


DEBILITY  OF   THE  LOWER  EXTREMITIES  19 

whether  irons  to  the  legs  can  ever  be  useful  in  a  state  (^f  paralysis 
of  the  lower  extremities.  If  the  limbs  are  paralytic,  how  are  irons 
to  the  legs  to  enable  the  patient  to  walk? — S.  M.)  At  the  end  of 
four  or  five  years,  some  have  by  this  means  got  better  in  proportion 
as  they  have  acquired  general  strength:  but  even  some  of  these 
have  been  disposed  to  fall  afterward  into  pulmonary  consumption, 
where  the  debility  has  not  been  entirely  removed." 

From  this  time  on  there  were  a  few  cases  reported,  including 
some  by  Shaw,^  w^ho  thought  that  the  disease  bore  some  relation 
to  weaning;  and  some  \'ague  paralytic  conditions  have  been  described 
by  Jorg,2  Bartsch,^  Bruck,*  and  Hutin.^ 

On  October  19,  1835,  Dr.  John  Badham,  of  Worksop,  Notts, 
sent  to  the  London  Medical  Gazette  an  article  entitled  "Paralysis  in 
Childhood:  Four  Remarkable  Cases  of  Suddenly  Induced  Paraly- 
sis in  the  Extremities,  Occurring  in  Children,  without  any  Apparent 
Cerebral  or  Cerebrospinal  Lesion."  This  was  published  Novem- 
ber 14,  1835.^ 

John  Badham  was  the  son  of  Professor  Badham,  quite  a  writer 
on  medical  topics  in  his  day.  He  describes  four  cases:  the  first, 
Ann  Hare,  aged  two  years,  who  had  a  paralysis  of  her  right  leg. 
"The  child  had  enjoyed  uninterrupted  health  up  to  the  evening 
of  her  attack,  with  the  exception  (if,  indeed,  it  can  be  so  called)  of 
slightly  augmented  thirst  and  some  drowsiness,  now  remembered 
by  the  mother  to  have  preceded  the  seizure  by  two  days.  On  the 
evening  of  August  13  the  child  was  put  to  bed,  having  run  about 
and  amused  herself  as  usual  during  the  day.  On  the  following 
morning  her  mother's  attention  was  first  attracted,  in  dressing  her, 
to  an  unusual  appearance  of  the  eyes,  which,  as  she  said,  appeared 
to  be  turned  inward.  (This  is  the  first  mention  of  cranial  nerve 
involvement.)  A  new  cause  of  apprehension  presented  itself  in 
putting  the  child  on  her  feet,  when  it  was  found  she  could  not  stand." 
On  examination  he  noted  that  "her  appearance  at  this  time  did 
not  denote  any  disease — she  was  playing  in  her  mother's  lap,  but 
on  examination  it  was  found  that  motion  in  the  right  leg  was  com- 
pletely destroyed,   and  in  the   left  somewhat  diminished,   while 

1  Nature  and  Treatment  of  the  Distortion  to  which  the  Bones  of  the  Spine  and 
Chest  are  Subject,  1822. 

2  Ueber  Verkriimniungen  des  Menschlichen  Korpers,  p.  85. 
'  Ammon's  Monatsschrift,  Band  ii,  Heft  1,  p.  7-1. 

*  Casper's  Wochenschrift,  1839,  No.  32. 

^  Sammlung  zur  Kenntniss  der  Gehirn  und  Riickenmarkskrankheitcn,  von  Nasse, 
Heft  2,  p.  10. 

^  London  Med.  Gaz.,  vol.  xxxvii;  vol.  i  for  the  Session  1835-1836,  p.  215. 


20  HISTORY  OF  POLIOMYELITIS 

sensation,  perfect  in  the  left  limb,  was  impaired,  without  being 
suspended  in  the  other."  The  child  was  treated  with  calomel  and 
blisters  and  other  things  used  in  those  days.  "  Under  this  treatment 
the  drowsiness  was  removed  in  five  days.  On  the  fourth,  indeed, 
from  its  adoption,  the  bell  of  the  right  eye  became  suddenly  liber- 
ated from  its  constrained  position;  the  other  eye  recovered  more 
slowly  a  few  days  afterward.  The  exercise  of  the  will  over  the 
affected  extremity,  though  entirely  abolished  at  first,  has  now  par- 
tially returned,  inasmuch  as  she  no  longer  drags  the  limb  after  her, 
as  she  at  first  did,  but  projects  or  flings  it  forward  with  a  jerk,  the 
direction  and  force  of  which  she  seems  not  to  have  the  slightest 
power  to  moderate  or  control. 

"My  second  case  singularly  occurred  a  few  days  afterward;  its 
subject  a  little  girl,  also  two  years  old,  who  had  been  seized,  a  week 
previously  to  my  seeing  her,  with  an  equally  sudden  loss  of  the  same 
extremity,  which  took  place  also  during  sleep,  without  any  prior 
intimation."    In  this  case  there  was  also  a  palsied  leg  as  the  result. 

Case  three  was  also  a  girl,  aged  two,  who  was  found  to  have  lost 
the  use  and  a  great  portion  of  the  sensibility  of  the  left  arm.  "The 
limb  is  now,  after  a  period  of  two  months,  hopelessly  paralyzed  and 
swings  like  a  suspended  object  attached  to  the  body." 

Case  four,  a  little  boy,  aged  two  years  and  a  half,  in  whom  the 
left  leg  was  paralyzed. 

Badham  makes  the  following  comments: 

"1.  The  extraordinary  youth  of  the  patients  is  to  be  noticed. 
It  will  be  observed  that  the  age  in  all  the  above  cases  correspond 
within  a  few  months. 

"2.  Although  each  case  was  either  preceded  by  or  ushered  in 
by  some  apparent  cerebral  sjniptoms — viz.,  in  two  by  drowsiness, 
in  the  others  by  an  abnormal  state  of  the  pupil — yet 

"3.  It  is  remarkable  that  in  no  one  instance  has  the  health  been 
in  any  degree  impaired. 

"4.  If  the  case  in  which  the  remarkable  strabismus  occurred 
should  lead  us  to  suspect  a  cerebral  complication,  rather  than  a 
spinal  one,  there  is  other  suspicion  of  congested,  oppressed,  or 
irritated  brain." 

The  first  monograph  on  the  subject,  and  indeed  a  very  remark- 
able one,  was  the  work  of  Jacob  Heine.  According  to  Baas  the 
Heines  were  a  family  whose  various  members  were  intimately 
connected  with  orthopedic  surgery.  The  family  began  with  Georg 
von  Heine  (1770-1838),  an  ex-farrier,  and  the  inventor  of  an  exten- 


DEBILITY  OF   THE   LOWER  EXTREMITIES  21 

sion  bed;  another  member,  Bernard,  was  the  first  to  use  osteotomy 
in  straightening  bones,  while  Jacol)  von  Heine  (1709-1878)  was  an 
orthopedie  surgeon  of  Cannstatt,  a  suburb  of  ^Stuttgart.  I  lis  son 
Karl,  afterward  a  professor  in  Prague,  was  also  noted  for  his  ortlio- 

BEOBACHTUNGEN 


ii  b  e  r 


lialimungrszustande  der  untern  Extre- 
mitaten  iind  deren  Beliandliiiig^. 


J.    Heine, 

Dr.  der  Mcdiciii  uud  Chirurgio,  Giiindci-  und  Vorsteher  dcr  orlhopUdischen  lleilaiuUll 
zii  CaiinstadI  a.  N. 


Mit  7  Steindrucktafeln. 


Franz     HcinrichKiihler. 

1  8  4  O. 

Fic.  1. — Title  pa^e  of  Heine's  first  monograph. 

pedic  writings.  Heine's  monograph  was  published  in  1840  under 
the  title  of  Beohachtungen  uber  Ldhnungszustdnde  der  iiniern  Extre- 
mitdten  mid  deren  Behandlmig.  It  is  a  volume  of  78  pages,  with  7 
lithographed  full-page  plates,  showing  22  figures  illustrating  deform- 


22 


HISTORY  OP  POLIOMYELlfiB 


ities  before  and  after  correction,  and  a  small  exercising  machine. 
He  starts  in  with  a  description  of  cases  which  he  has  observed, 
including  14  cases  of  paraplegia,  7  cases  of  hemiplegia,  and  6  cases 
of  partial  paralysis  in  which  only  one  or  more  muscle  groups  were 


flfS 


Fig.  2. — Showing  the  remarkably  good  results  obtained  by  Heine  by  orthopedic 
treatment.  Picture  on  the  left  shows  the  condition  of  the  patient  on  entrance  and  on 
the  right  on  leaving  the  hospital. 


affected.  After  the  description  of  his  cases  he  takes  up  a  consid- 
eration of  the  symptomatology,  and  gives  in  a  very  clear  manner 
the  most  important  features  of  the  disease  as  we  know  them  today. 
He  made  some  special  observations  on  the  temperature  of  the 


DEBILITY  OF   THE  LOWER  EXTREMITIES 


23 


paralyzed  extremities  as  compared  to  the  unaffected  members. 
Another  chapter  is  devoted  to  the  etiology,  and  there  is  one  on 
the  pathological  anatomy.  He  also  considers  the  subject  of  diag- 
nosis  and  prognosis,  and  devotes  a  considerable  chapter  to  the 


Fig.  3. — Showing  some  other  results  on  entering  and  leaving  the  hospital,  also  an 
arm  case  and  a  simple  apparatus  for  exercising  the  legs. 


therapy,  in  which  he  recommends  exercise  and  baths,  the  use  of  a 
simple  device  for  exercising  the  legs,  various  simple  surgical  proce- 
dures to  be  followed  by  the  use  of  apparatus  well  shown  in  some  of 
his  illustrations  which  we  have  reproduced. 


24 


HISTORY  OF  POLIOMYELITIS 


In  1860,  twenty  years  later,  a  second  edition  of  the  book  was 
published,  a  monograph  of  204  pages  with  14  plates.  This  time 
the  authorship  of  the  volume  is  given  ^s  Jacob  von  Heine,  and  the 
name  is  followed  by  a  considerable  list  of  titles  and  honors  that 


Fig.  4. — Shows  the  use  of  orthopedic  apparatus  and  the  excellent  results  that  were 

obtained. 


had  been  bestowed  upon  him.  The  book  gives  some  further  studies 
of  actual  cases  and  a  review  of  the  literature,  together  with  valu- 
able chapters  on  diagnosis,  prognosis,  and  therapy,  and  it  is  inter- 
esting to  note  the  title  of  the  monograph  was  changed  to  Spinale 


MEDICAL  NOTES  25 

KindcrJiiJwnnui  (hifantile  Spinal  Paralysu).  Heine's  original 
monograph  was  followed  by  the  appearance  of  a  considerable  num- 
ber of  observations  by  various  other  writers.  Henry  Kennedy, 
M.K.I. A.,  published  an  article/  and  subsequently,  in  ISoO,^ 
another  on  some  of  the  forms  of  paralysis  which  occur  in  early  life. 
Kennedy  was  a  prominent  Irish  physician,  a  fellow  of  Kings  and 
Queens  College  of  Physicians  in  Ireland,  and  Temporary  Physician 
to  the  Court  Street  Hospital.  He  does  not  mention  Heine,  and  it 
is  fair  to  presume  he  did  not  know  about  his  work.  He  noted  that 
temporary  paralysis  was  of  tolerably  frequent  occurrence  and 
thought  that  the  arm  was  more  frequently  paralyzed  than  the  leg, 
but  that  in  young  infants  the  diagnosis  of  paralysis  of  the  leg  was 
more  apt  to  be  made.     He  recommended  warm  baths  for  the  pain. 

West  also  wrote  about  the  disease  in  the  London  Medical  Gazette 
In  1845,  and  described  it  in  his  text-book  of  Diseases  of  Children 
in  1848.  In  France,  Barthez  and  Rilliet  described  the  disease  in 
their  remarkable  work  on  the  Diseases  of  Children,  and  there  is 
a  special  article  by  Rilliet  in  which  he  called  the  disease  the  essen- 
tial paralysis  of  children.-^  They  had  an  opportunity  of  making  an 
autopsy,  but  did  not  notice  any  changes  in  the  nervous  system,  and 
so  called  it  the  essential  paralysis.  In  America  the  first  epidemic 
was  described  by  Colmer,^  1843.     This  entire  article  is  as  follows: 

Medical  Notes.  By  George  Colmer.  —  Paralysis  in  Teething 
Children. — "  While  on  a  visit  to  the  parish  of  West  Feliciana,  La., 
in  the  fall  of  1841,  my  attention  was  called  to  a  child,  about  a  year 
old,  then  slowly  recovering  from  an  attack  of  hemiplegia.  The 
parents  (who  were  people  of  intelligence  and  unquestionable  verac- 
ity) told  me  that  8  or  10  other  cases  of  either  hemiplegia  or  para- 
plegia had  occurred  during  the  preceding  three  or  four  months 
within  a  few  miles  of  their  residence,  all  of  which  had  either  com- 
pletely recovered  or  were  decidedly  improving.  The  little  sufferers 
were  invariably  under  two  years  of  age,  and  the  cause  seemed  to 
be  the  same  in  all — namely,  teethitig." 

All  these  earlier  writers  ascribed  the  disease  to  teething  or  to 
weaning,  except  Heine,  who  recognized  that  he  had  to  deal  with 
a  disease  of  the  spinal  cord.  In  1855  Duchenne,  of  Boulogne, 
called  it  fatty  infantile  atrophic  paralysis,  and  later  he  shortened 
the  name   to  infantile  atrophic  paralysis.     He  gave  an  admirable 

'  Dublin  Med.  Press,  September  29,  1841. 
2  Dublin  Quart.  Jour.  Med.  Sc,  ix,  85. 
3Gaz.  Med.,  1851,  p.  681. 
•Am.  Jour.  Med.  Sc,  1843,  v,  248. 


26  HISTORY  OF  POLIOMYELITIS 

study  of  cases,  and  suggested  the  use  of  faradic  electricity,  both  in 
prognosis  and  in  treatment,  and  stated:  "All  the  cases  of  infantile 
paralysis  which  I  have  seen  where  the  faradic  contractility  was 
demonstrated  and  not  lost  and  which  could  be  treated  with  faradic 
electricity,  within  two  years  after  the  onset,  have  been  completely 
recovered." 

In  1856  there  was  an  excellent  article  by  Chassaignac.^  He 
described  it  as  a  painful  paralysis  of  young  children,  and  in  14 
cases  only  found  one  in  the  leg.  He  describes  graphically  the  sud- 
den onset,  the  completeness  of  the  paralysis,  and  the  pain. 

The  first  historical  period  embraces  the  time  from  Underwood, 
in  1784,  to  Heine's  second  publication  in  1860,  and  practically  this 
might  be  shortened  to  include  the  time  between  Heine's  two  contri- 
butions. This  was  the  period  of  the  investigation  of  the  clinical 
history,  with  little  or  no  knowledge  of  the  pathological  processes 
involved.  The  second  period,  or  the  period  of  the  study  of  the 
pathological  anatomy,  dates  from  1863,  and  might  be  closed  with 
the  publication  of  Medin's  article,  which  introduced  the  modern 
era  of  the  understanding  of  poliomyelitis.  There  had  been  a 
number  of  autopsies  made  prior  to  1863.  Seeligmiiller^  gives  a  table 
of  cases  beginning  with  Hutin,  in  1825.  Hutin's  findings  are  com- 
mented on  at  length  by  Heine.  In  this  case  both  legs  were  par- 
alyzed, and  from  the  eighth  dorsal  nerve  downward  there  was  a 
marked  shrinking  of  the  spinal  cord  to  the  thickness  of  an  ordinary 
lead-pencil,  and  the  spinal  nerves  were  also  atrophied.  In  1829 
Klein  found  a  congestion  of  the  pia  around  the  roots  of  the  left 
brachial  plexus  (quoted  by  Heine).  In  1842  Longet^  described  the 
findings  in  the  case  of  a  girl,  aged  eight  years,  whose  right  leg  was 
paralyzed.  He  found  an  atrophy  and  a  brownish  discoloration  of 
the  lumbar  and  sacral  nerves  going  to  the  sciatic.  Fliess,^  in  1849, 
described  a  congestion  of  the  meninges  in  the  neighborhood  of  the 
roots  of  the  arm  nerves.  These  and  several  other  observations  of 
a  negative  character  represent  the  pathological  findings  up  to  1863, 
when  von  Reinecker  and  von  Recklinghausen^  described  an  atro- 
phy and  degeneration  of  the  ganglion  cells  and  nerve  fibers  of  the 
anterior  horns  of  the  cord.  In  the  same  year  Cornil^  described  atro- 
phy of  the  anterior  lateral  columns  and  atrophy  of  the  anterior 
ganglion  cells.     In  1864  Bouvier  and  Laborde  and  Cornil  and 

1  De  la  Paralysie  Douloureuse  des  jeunes  Enfants,  Arch.  Gen.  de  Med.,  1856. 

2  Gerhardt's  Handbuch  der  Kinderkrankheiten,  vol.  v,  Part  I;  second  half,  p.  15. 
3Anat.  u.  Phy.siol.  d.  nerven  System.  ^  Jour.  f.  Kinderkr.,  xiii,  39. 

s  Deutsch.  Klinik,  January  31,  1863.  ^  Qaz.  Med.,  1864,  p.  290. 


n 

MEDICAL  NOTES  27 

Laborde  described  cases  in  which  they  noted  a  sclerosis  of  the 
anterior  cohimns  and  an  increase  in  the  connective  tissue.  In  1865 
Prevost'  noted  the  atrophy  of  the  gray  matter  of  the  left  anterior 
horns,  and  especially  of  the  ganglion  cells.  In  the  following  year, 
18C6,  Echeverria  noted  a  diffuse  myelitis  and  changes  in  the  anterior 
horns  and  pigmentation.  In  1870  Charcot  and  Joffroy-  described 
the  atrophy  of  the  ganglion  cells  and  of  the  anterior  horns  and  the 
anterior  nerve  roots;  and  Parrot  and  Joffroy^  the  atrophy  of  the 
ganglion  cells  and  sclerosis  of  the  anterior  lateral  columns.  These 
observations  were  confirmed  by  Vulpian,^  who  noted  the  atrophy 
and  degeneration  of  the  ganglion  cells  and  nerve  fibers,  and  by 
Roger  and  Damaschino,*  who  described  foci  and  softening  through- 
out the  cord,  together  with  atrophy  of  the  ganglion  cells  and  nerve 
fibers,  sclerosis  of  the  anterior  columns  and  atrophy  of  the  anterior 
roots.  They  also  described  degeneration  of  the  bloodvessels.  Others 
who  confirmed  these  findings  are  Seeligmiiller,  Lancereaux  and 
Pierret,  Leiden,  Raymond,  Demme,  Schultze,^  and  a  few  other 
workers,  references  to  which  will  be  found  in  Seeligmiiller's  article 
or  in  the  excellent  article  by  Mary  Putnam  Jacobi.^  There  was 
considerable  discussion  in  the  medical  literature  over  the  nature 
of  the  changes,  Charcot  believing  it  to  be  a  primary  atrophy  and 
others  having  other  views,  which  were  argued  back  and  forth  at 
considerable  length.  The  histological  changes  were  studied  by 
Roger  and  Damaschino  and  by  Clarke  and  Schultze,  but  it  was  not 
until  the  time  of  Rissler^  that  any  definite  studies  were  made  upon 
the  acute  cases.  Rissler  studied  3  cases  that  died  between  the 
fifth  and  eighth  days,  and  gave  a  very  accurate  description  of  the 
changes  found.  Since  his  time  there  have  been  several  dozen 
reports  dealing  with  the  histological  changes  occm-ring  in  the  acute 
cases,  the  most  important  of  which  are  those  of  Harbitz  and  Scheel 
(1907),  who  reported  the  changes  on  13  cases,  Wickman  (1905 
and  1910),  who  studied  14  cases,  Strauss  (1910)  who  studied  S 
cases  and  the  splendid  study  of  Peabody,  Draper  and  Dochez  in 
1912. 

In  1884  the  first  accurate  account  of  the  cerebral  type  of  the 
disease  was  given  by  Striimpell.     (See  Cerebral  Type.)    The  first 

1  Gaz.  M6.d.,  1866.  =  Arch,  de  Physiol.,  1870,  p.  130. 

3  Ibid.,  p.  310.  ■•  Ibid.,  p.  316. 

6  Gaz.  Med.,  1871,  p.  457.  «  Virchows  Arch.,  Ixviii,  109. 

'  Pepper's  System  of  Medicine,  v,  1113. 

*  Zur  Kenntniss  der  Veriindeningen  des  ncrven  Systems  bei  Poliomyelitis  Anterior 
acuta,  Nord.  med.  Ark.,  1888. 


28  HISTORY  OF  POLIOMYELITIS 

adult  case  was  described  by  Vogt^  in  1859.  Moritz  Meyer,  in  1868, 
reported  2  cases  in  grown  people,  and  in  1872  Duchenne  reported 
quite  a  series,  and  subsequently  Bernhardt,  Charcot,  Kussmaul, 
Erb,  Hammond,  Schultze  and  others,  studied  adult  cases.  These 
were  quoted  by  Seguin.^ 

Various  special  phases  of  the  disease  were  studied,  such  as  the 
reaction  to  galvanic  electricity  by  Erb,  and  to  faradic  electricity 
by  Duchenne,  of  Boulogne,  but  up  to  Medin's  study^  of  the  Stock- 
holm epidemic  of  1887  the  nature  of  the  disease  was  not  understood, 
although  Striimpell  and  Pierre  Marie  had  recognized  that  it  was 
an  infection,  as  evidenced  by  the  symptoms  and  course  of  the 
cases  in  the  early  stage  of  the  disease.-  To  Medin,  however,  belongs 
the  credit  of  placing  the  disease  definitely  in  the  class  of  those  which 
occur  as  epidemics.  This  he  first  did  before  the  Medical  Congress 
of  1890.  Epidemics  of  the  disease  had  been  recognized  before,  but 
the  infectious  character  was  apparently  not  even  suspected.  Medin 
gives  credit  for  recognizing  an  epidemic  as  early  as  1881  to  Bergen- 
holz,  who  noted  13  cases  occurring  in  the  department  of  Norrbotten. 
Cordier^  also  described  13  cases  occurring  in  the  environs  of  Lyons. 
Leegaard,  in  September,  1886,  described  9  cases  in  and  about 
Mandel  in  Norway,  while  in  America,  MacPhaiP  and  Caverly^ 
reported  the  first  extensive  American  epidemic,  occurring  in  Ver- 
mont. Following  Medin  the  ill-fated  Ivan  Wickman,  his  student 
and  assistant,  studied  the  Norwegian  epidemic  of  1905  and  pub- 
lished one  of  the  most  striking  monographs  on  the  subject  that 
has  yet  appeared.  His  monograph  includes  a  very  thorough  study 
of  the  epidemiology  of  the  disease,  and  he  deserves  special  credit 
for  recognizing  and  describing  the  so-called  abortive  or  non-paralytic 
cases.  For  a  number  of  years  no  special  additions  were  made  to 
our  knowledge  of  the  disease.  Lumbar  puncture  was  done  in  a 
case  of  Landry's  type  on  the  thirteenth  day  by  Schultze,  and  he 
described  a  diplococcus;  and  since  that  time  numerous  authors 
have  described  bacteria  of  one  kind  or  another.  The  earliest  inocu- 
lation experiments  were  those  of  Biilow,  Hanson  and  Harbitz  in 
1899.  Their  observations  were  made  on  rabbits,  and  were  not 
successful. 

*  Ueber  die  Essentielle  Lahmungen  der  Kinder,  Berne,  1859;  Schwietzer  Monats- 
schrift  f.  prakt.  Med.,   1857-8-9. 

2  Monograph,  1874. 

3  Arch,  des  Medecine  des  Enfants,  May-June,  1898,  pp.  257-320. 
^  Lyons  Med.,  1888,  Ivi,  548. 

5  Med.  News,  Philadelphia,  1894,  p.  619.  «  Med.  Record,  1894,  xlvi,  673. 


MEDICAL  NOTES  29 

The  disease  was  produced  in  monkeys  for  the  first  time  })y  Land- 
steiner  and  Popper^  and  ahnost  at  the  same  time  by  Flexner  and 
Lewis,^  and  by  Strauss^  in  America.  In  1909  three  different  observ- 
ers, working  independently,  succeeded  in  transmitting  the  disease 
from  one  monkey  to  another.  These  were  Flexner  and  I^ewis  in 
New  York,  Leiner  and  von  Wiesner*  in  Vienna,  and  Landsteiner 
and  Levadidti"^  in  Paris.  In  the  same  year  Flexner  and  Lewis  and 
Landsteiner  and  Levaditi  also  discovered  the  fact  that  the  virus 
was  filtrable,  and  this  was  quickly  followed  by  the  observation 
of  Flexner  and  Lewis^  that  recovery  from  an  attack  of  experimental 
poliomyelitis  afforded  protection  to  a  second  inoculation.  Subse- 
quently, neutralizing  or  immunizing  substances  were  discovered  in 
the  blood  serum  of  monkeys  that  had  recovered  from  the  disease, 
as  produced  experimentally,  and  this  was  followed  by  finding  them 
in  the  blood  serum  of  human  beings  who  had  had  the  disease  by 
Levaditi  and  Landsteiner,^  Romer  and  Joseph,^  Flexner  and  Lewis,^ 
Anderson  and  Frost.^^  The  next  step  in  the  understanding  of  the 
disease  came  when  Flexner  and  Lewis,  in  1910,  were  able  to  obtain 
some  rather  definite  results  in  monkeys  in  attempting  to  prevent 
the  development  of  the  disease  through  the  administration  of  blood 
serum  either  from  recovered  monkeys  or  from  recovered  human 
beings.  They  found  that  monkeys  that  had  been  injected  with 
the  virus  could,  in  some  cases,  be  saved,  while  in  others  the  onset 
was  delayed  by  the  intraspinal  injections  of  the  immune  serum. 
This  method  was  very  soon  used  by  Netter  and  his  co-workers," 
and  they  established  the  fact  that  injections  of  immune  serum  could 
be  made  in  man  in  poliomyelitis  with  safety.  The  most  probable 
organism  was  described  by  Flexner  and  Noguchi  in  1913. 

Various  other  points  of  recent  historical  interest  will  be  found 
scattered  throughout  the  text. 

1  Ztschr.  f.  Immunitatsforsch.,  original,  1909,  ii,  377. 

2  Jour.  Am.  Med.  Assn.,  1909,  liii,  1639. 

3  New  York  Med.  Jour.,  1910,  xci,  64. 

*  Wien.  klin.  Wchnschr.,  1909,  xxii,  1698. 

6  Compt.  rend.  Soc.  de  biol.,  1909,  Ixvii,  592. 

^  Jour.  Am.  Med.  Assn.,  1916,  liv,  45. 

'  Compt.  rend.  Soc.  de  biol.,  1910,  Ixviii,  311. 

8  Miinchen.  med.  Wchnschr.,  1910,  Ivii,  968. 

'  Jour.  Am.  Med.  Assn.,  1910,  Hv,  178. 
'»  Jour.  Am.  Med.  Assn.,  1911,  Ivi,  663. 

11  Netter,  Gendron  and  Touraine:  Compt.  rend.  Soc.  de  biol.,  1911,  Ixx,  625. 
Netter:  Bull,  de  I'Acad.  de  med.,  1915,  Ixxiv,  ser.  3,  403.  Netter  and  Salanier: 
Bull,  et  mem.  Soc.  med.  Hop.  de  Paris,  1916,  xl,  s6r.  3,  299. 


CHAPTER  II. 

A  CONCEPTION  OF  THE  DISEASE. 

In  order  to  understand  poliomyelitis,  one  should  remember  that 
it  is  a  disease  due  to  a  filtrable  virus,  the  portal  of  entry  of  which 
has  not  definitely  been  determined  in  cases  occurring  under  natural 
conditions,  but  the  virus  has  been  found  in  the  nasopharynx,  and 
the  disease  may  be  transmitted  by  rubbing  the  virus  into  scarified 
or  normal  mucous  membrane  of  the  nasopharynx.  It  may  be  pro- 
duced by  injecting  the  virus  directly  into  the  nervous  system,  and 
in  the  cases  in  which  infection  has  been  produced  by  rubbing  the 
virus  into  the  nasopharynx,  it  is  possible  that  the  virus  may  get 
into  the  nervous  system  directly  through  the  nerves  passing  through 
the  ethmoid  into  the  brain  or  through  lymph  channels,  or  it  may 
circulate  in  the  blood  and  reach  the  nervous  system  through  the 
choroid  plexus.  Amoss  and  Flexner^  have  shown  that  if  the  virus 
is  injected  directly  into  the  blood  stream  there  is  a  tendency  for  the 
virus  to  be  withdrawn  from  the  circulation  into  the  bone  marrow  and 
spleen  in  spite  of  the  apparent  affinity  that  the  virus  seems  to  have 
for  nervous  tissue.  If,  however,  very  large  quantities  are  given 
the  virus  may  get  into  the  nervous  system  from  the  blood  stream, 
or  if  ordinary  amounts  are  used  and  a  sterile  meningitis  set  up 
by  the  injection  of  horse  serum,  the  virus  probably  gets  into  the 
nervous  system  through  the  injured  choroid  plexus.  The  disease  in 
the  human  being  is  to  be  regarded  as  a  general  infection,  in  which, 
probabh^,  most  of  the  cases  have  slight  general  sjinptoms  and  may 
escape  diagnosis.  These  cases  are  sometimes  called  abortive  or  non- 
parahi;ic.  (See  same.)  In  certain  other  cases  the  child  is  taken 
ill,  and  after  one  or  two  or  three  days  gets  better,  sometimes 
almost  well,  and  then  is  again  taken  ill  with  the  production  of  paraly- 
sis. This  group  Draper^  has  cafied  the  dromedary  group,  on  account 
of  the  sjTiiptoms  coming  on  in  two  successive  humps,  as  it  were. 
In  the  non-paralytic  cases  the  virus  probably  never  gets  into  the 
nervous  system,  or  if  so,  is  neutralized  before  it  produces  any  seri- 

1  Jour.  Exper.  Med.,  1914,  p.  249. 

2  Jour.  Am.  Med.  Assn.,  April  21,  1917,  p.  1154. 


A   CONCEPTION  OF  THE  DISEASE  31 

oils  damage.  In  the  dromedary  group  the  virus  in  the  blood  pro- 
duces the  s^inptoms  of  a  general  infection  and  then  it  gains  entrance 
to  the  nervous  tissue  with  the  production  of  paralyses  and  other 
nervous  s.Mnptoms. 

In  another  group  of  cases  the  child  is  ill  for  two  or  three  or  more 
days  and  there  is  no  remission  in  the  illness,  and  these  are  doubt- 
less cases  in  which  the  original  dose  of  the  virus  is  either  greater  or 
more  intense,  or  else  the  individual's  resistance  is  lower,  and  the 
symptoms  of  a  general  infection  keep  up  until  the  nervous  symptoms 
are  manifest. 

And,  lastly,  there  is  a  group  in  which  the  nervous  sjTnptoms 
may  be  marked  from  the  first,  and  these  may  doubtless  be  due  to 
either  the  virus  reaching  the  nervous  system  immediately  on  its 
entrance  to  the  body  or  to  the  original  infection  producing  very 
slight  general  symptoms  for  some  reason  or  other. 


CHAPTER    III. 

PATHOLOGY. 

As  far  as  we  have  seen  the  portal  of  entry  of  the  virus  into  the 
body  is  not  definitely  known,  but  it  seems  highly  probable  that  it 
is  in  the  nasopharynx,  from  whence  the  virus  either  travels  along 
the  nerves  to  the  meninges  or,  what  seems  more  probable,  that  it 
invades  the  lymphatic  system  and  is  carried  in  that  way  to  the 
various  parts  of  the  body.  The  earlier  observers,  having  in  mind 
the  de^'astating  effects  upon  the  nervous  system,  devoted  most  of 
their  time  to  the  study  of  the  changes  in  the  cord  and  brain,  but 
Rissler  (in  1888),  Medin  (in  1890),  Harbitz  and  Scheel,  Strauss, 
Wickman  and  others  observed  and  described  the  changes  in  the 
other  tissues  of  the  body,  although  they  did  not  attach  .very  much 
importance  to  them.  The  earlier  studies  were  also  made  upon  old 
cases  and  the  lesions  described  by  them  of  the  scarring  that  occurs 
in  the  cord  as  noted  below. 

The  disease,  in  place  of  being  a  local  infection,  is  to  be  regarded 
as  a  general  infection.  As  in  the  case  of  most  infectious  diseases 
the  virus  of  poliomyelitis  shows  a  distinct  tendency  to  localize  in 
certain  tissues,  generally  the  nervous  system  and  the  lymphoid 
system.  Changes  are  observed  in  the  other  organs,  particularly  in 
the  fatal  cases.  In  dealing  with  a  general  infection  with  a  localizing 
tendency  one  has  to  consider  not  only  the  fact  that  it  affects  cer- 
tain tissues  but  that  it  affects  them  in  different  cases  to  various 
degrees.  In  poliomyelitis,  in  some  of  the  cases,  the  changes  are 
doubtless  very  transient,  which  explains  the  abortive  cases  and 
those  with  a  transient  paralysis.  In  others  the  lesions  are  of  mod- 
erate seA'erity,  with  a  distinct  tendency  to  clear  up  so  that  the 
ultimate  paralysis  is  trifling  compared  to  that  which  is  seen  at 
first.  In  still  other  cases  the  amount  of  damage  done  is  extensive 
and  beyond  repair,  while  in  many  the  destruction  may  be  so  wide- 
spread or  affect  such  centers  as  to  cause  death. 

The  cerebrospinal  fluid  is  usually  somewhat  increased  and  shows 
certain  changes  described  in  the  section  on  that  subject.  The 
earliest  changes  consist  of  a  congestion  affecting  the  bloodvessels 


PATHOLOGY  OF  POLIOMYELITIS 


33 


supplying  the  meninges,  the  brain,  and  spinal  cord,  and  this  shows 
a  tendency  to  be  asymmetrical.  Along  with  this  congestion  there 
is  an  exudate  of  small  round  cells,  probably  lymphocytes,  which 


ant 


a.  spin,  post 


spin,  post. 


Fig.  5. — Dots  show  chief  areas  of  disease  in  acute  poliomyelitis. 


Fig.  6. — Acute  poliomyelitis.     Photograph  showing  the  swollen  ghost-like  ceils  of 
Clarke's  column  and  the  surrounding  cellular  infiltration  of  the  tissues. 


34 


PATHOLOGY  OF  POLIOMYELITIS 


crowd  the  perivascular  hTaph  spaces  of  the  leptomeninges,  but 
there  is  no  exudate  to  amount  to  anything  and  no  deposits  of  fibrin. 
The  changes  are  most  marked  in  the  places  in  which  the  cord  is 
most  vascular — that  is,  in  the  cervical  and  lumbar  regions,  and 
particularly  the  anterior  part  of  the  cord  and  the  anterior  fissure 
in  which  run  the  vessels  supplying  the  anterior  part  of  the  cord. 
There  are,  however,  changes  throughout  the  cord  and  also  in  the 
posterior  region.    The  exudate  of  small  round  cells  and  the  hyper- 


FiG.  7. — Acute  poliomj'elitis.     An  anterior  cornual  cell  in  fair  preservation, 
although  surrounded  on  all  sides  by  inflammatorj^  cells. 


emia  around  the  bloodvessels  of  the  cord  may  be  so  great  as  to  cause 
an  obstruction  of  the  circulation  at  certain  points.  With  this  there 
is  a  more  or  less  marked  edema.  Throughout  both  the  gray  and 
white  nervous  tissue  may  be  seen  small  punctate  hemorrhages, 
occasionally  even  larger  ones.  The  exudate,  the  hemorrhages,  and 
the  edema  and  the  toxic  action  of  the  virus  produce  changes  in  the 
nerve  cells.  It  is  impossible  to  state  how  much  of  the  change  is 
due  to  the  toxic  action  and  how  much  is  due  to  the  mechanical 
changes — that  is  the  anemia  which  follows  the  pressure  upon  cer- 
tain vessels.  The  lesions  are  always  worse  in  certain  areas  and 
shade  off'  into  the  surrounding  portions  of  the  cord,  which  explains 
the  fact  that  the  initial  paralysis  is  almost  always  of  a  very  much 
greater  extent  than  that  which  becomes  permanent,  as  a  large 


PATHOLOGY  OF  POLIOMYELITIS 


35 


number  of  nerve  cells  are  temporarily  interfered  with,  and  as  the 
exudate  is  absorbed  the  edema  disappears  and  the  congestion  grows 
less;  these  cells  recover  entirely,  whereas  the  cells  which  are  in  the 
part  most  affected  may  be  permanently  damaged,  and  these  may 
be  seen  in  all  stages  of  destruction  and  degeneration,  from  those 
which  show  only  very  slight  changes  to  those  which  have  become 
necrotic  and  granular.  In  these  latter  areas  the  polymorphonuclear 
neutrophils  invade  the  nerve  cells  by  their  phagocytic  action, 
remove  the  necrotic  tissue,  and  so  pave  the  way  for  the  late  changes 
which  take  place. 


S&^5^ 


Fig.  S. — Acute  poliomj-elitis.  This  photograph  illustrates  the  fact  that  the 
vessels  of  the  posterior  arterial  system  are  involved,  as  well  as  the  branches  of  the 
anterior  spinal  artery.     This  vessel  lies  in  the  posterior  median  fissure. 


In  the  brain,  pons,  and  medulla  similar  changes  may  be  noted. 
Lesions  follow  the  distribution  of  the  blood  supply,  but  are  usually 
not  sufficiently  extensive  to  produce  motor  changes.  In  some 
instances  the  changes  may  be  limited  to  the  upper  neuron  tracts, 
and  such  cases  were  first  described  by  Striimpell  in  18S5.  These 
cases  are  considered  more  at  length  in  the  section  dealing  with  the 
clinical  history  of  the  disease.  In  many  instances  the  clinical  symp- 
toms and  the  changes  noted  at  autopsy  do  not  coincide,  but  these 
discrepancies  will  probably  be  cleared  up  by  further  histological 
studies. 

In  the  posterior  nerve  roots  the  lesions  are  of  almost  constant 


36 


PATHOLOGY  OF  POLIOMYELITIS 


occurrence  and  the  changes  are  like  those  which  take  place  in  that 
cord.  An  infiltration  of  small  mononuclear  cells  in  the  space  sur- 
rounding the  bloodvessels  supplying  the  ganglia  and  the  degenera- 
tion and  necrosis  of  the  nerve  cells  may  occur  in  the  early  cases, 
and  the  phagocytic  action  of  the  leukocytes  is  also  present  and  dis- 
poses of  the  necrotic  material  as  explained  before.  There  is  also 
infiltration  of  the  cells  along  the  nerve  roots.  Involvement  of  the 
sensory  ganglia  may  explain  the  pain  so  common  in  the  acute  cases. 
The  changes  in  the  old  cases  consist  of  an  atrophy  of  the  cord, 
which  is  most  often  limited  to  one  lateral  half  of  the  cord;  but  in 


Fig.  9. — Acute  poliomyelitis.    Dense  cellular  exudation  and  proliferation  in  the  ante- 
rior gray  matter  of  the  lumbar  cord.     All  the  ganglion  cells  have  disappeared. 


this,  of  course,  there  is  a  great  variation  according  to  the  amount 
of  original  destruction.  The  changes  are  of  a  sclerotic  character 
and  the  scarring  of  the  cord  on  section  is  very  apparent.  The 
lesions  are  often  only  in  one  anterior  horn.  The  ganglion  cells  are 
either  wanting  entirely  or  diminished  in  numbers  or  else  so  degen- 
erated that  they  can  scarcely  be  recognized.  The  fibers  of  the 
anterior  horn  are  also  degenerated  and  the  nerve  trunks  are  atro- 
phied and  degenerative  changes  have  taken  place.  The  white 
matter  of  the  cord  is  aflfected  to  a  very  much  less  extent.  There  is 
degeneration  and  atrophy  of  the  anterior  nerve  roots  and  of  the 


PATHOLOGY  OF  POLIOMYELITIS 


37 


nerves  and  muscles  themselves.    The  muscle  fibers  are  often  degen- 
erated as  well  as  atr()i)hied,  and  in  many  cases  replaced  by  fibrous 


Fig.  10. — Acute  poliomyelitis.  Anterior  edge  of  cord  in  lumbar  region.  An 
anterior  root  bundle  is  seen  passing  through  the  soft  meninges,  which  are  infiltrated 
with  round  cells. 


Fig.  11. — Acute  poliomyelitis.  From  a  case  which  died  on  the  fourth  day  of 
illness.  Twelfth  dorsal  segment.  Note  the  swollen  and  prominent  aspect  of  the 
gray  matter  and  the  dark  outlines  of  the  radial  vessels  in  the  white  columns,  due 
to  intense  perivascular  round-cell  infiltration. 


tissue.    The  afl'ected  extremities  grow  more  slowly,  and  after  two 
years  from  the  onset  the  patient  can  be  said  to  be  in  the  final  or 


38  PATHOLOGY  OF  POLIOMYELITIS 

atrophic  stage.  The  bones  are  smaller  and  show  atrophy,  which  is 
apparent  to  casual  examination,  and  it  has  also  been  demonstrated 
at  autopsy  and  by  .r-ray  examinations.  As  the  child  grows  there 
are  often  deformities  of  the  bones  and  shortening  of  the  entire 


Fig.  12. — Pciliomyelitis.  High  power,  showing  complete  absence  of  cells  in  the 
horn;  bloodvessels  and  scar  tissue  remaining  and  liquefaction  of  the  tissue.  The 
child's  thigh  and  leg  were  atrophic  and  totally  paralyzed.     (Larkin.) 


extremity,  due  to  pulling  of  muscles  that  remain  paralyzed.  This 
condition  is  described  somewhat  more  fully  under  the  symptoma- 
tology of  the  late  cases. 

The  changes  in  the  other  organs  have  been  noted  by  numerous 
observers,  among  them  Rissler,^  Harbitz  and  Scheel,  Medin,  Wick- 

1  Zur  Kenntniss  der  Veranderungen  des  nerven  Systems  bei  Poliomyelitis  Anterior 
acuta,  Nord  Med.  Arch.,  1888,  xx,  1. 


PATHOLOGY  OF  POLIOMYELITIS  39 

man  and  Strauss.  These  changes  are  of  very  constant  appear- 
ance. Next  to  the  nervous  tissue  the  virus  seems  to  have  a  distinct 
tendency  to  involve  the  lymphoid  tissue  and,  perhaps,  to  a  lesser 
extent,  the  parenchymatous  organs.  The  most  striking  changes  in 
the  lymphoid  tissue  are  met  with  in  Peyer's  patches  of  the  intestine 
and  the  mesenteric  lymph  nodes.  Sometimes  the  lymph  nodes  in 
other  parts  of  the  body  may  be  enlarged,  such  as  the  axillary,  cer- 
vical, and  inguinal,  and  also  the  substernal  and  bronchial  nodes; 
the  lymph  tissues  on  the  throat  are  also  affected,  the  tonsils  and 
adenoids  and  other  lymph  structures.  The  thymus  is  also  involved. 
Some  of  the  enlarged  lymph  nodes  are  more  or  less  normal  on  his- 
tological study,  but  usually  they  show  the  invasion  of  a  zone  of 
lymphocytes  about  pale  centers  that  are  made  up  largely  of  endo- 
thelial cells.  The  spleen  may  be  slightly  enlarged,  and  on  section 
the  Malpighian  corpuscles  are  prominent.  The  changes  in  these 
organs  as  well  as  those  of  the  other  parenchymatous  organs  suggest 
those  met  with  in  other  infectious  diseases.  In  the  liver  cell  necroses 
of  varying  extent  are  met  with,  sometimes  only  one  or  two  cells 
being  involved,  other  times  a  considerable  portion  of  a  lobule  being 
affected. 


CHAPTER  IV. 
THE  NATURE  OF  THE  VIRUS. 

The  virus  can  be  filtered  through  a  Berkefeld  filter,  which  places 
the  disease  among  those  ordinarily  classed  as  being  caused  by  a 
filterable  virus.  The  virus  withstands  exposure  to  light,  heat,  cold, 
and  drying  rather  more  than  do  the  ordinary  bacteria.  It  will 
retain  its  virulence  in  the  height  of  the  summer  heat  even  when 
dried  on  pieces  of  clothing,  and  it  is  not  destroyed  by  the  action 
of  ordinary  weak  chemicals.  It  withstands  glycerination  a  long 
time,  and  is  not  injured  by  0.5  per  cent,  phenol.  It  may  be  frozen 
at  —2°  C.  to  —4°  C.  for  four  days  without  materially  affecting  it. 
It  is  destroyed  by  heating  one-half  hour  at  from  45°  to  50°  C.  It  is 
also  destroyed  by  exposure  to  sunlight  and  by  the  action  of  2  per 
cent,  hydrogen  peroxide,  by  menthol  solutions,  mercuric  bichloride, 
iodin,  and,  in  fact,  by  any  of  the  stronger  disinfectants.  Ordinary 
solutions  used  in  the  nose  and  throat  as  preventives  do  not  prevent 
the  development  of  the  disease. 

The  virus  obtained  from  the  human  body  is  not  particularly 
infective  for  monkeys,  and  it  has  to  be  used  in  amounts  and  under 
conditions  that  may  be  regarded  as  artificial.  There  are  great 
variations  in  the  strength  of  the  virus,  both  as  it  occurs  in  human 
beings  and  in  monkeys.  In  the  human  being  it  is  probably  most 
infective  during  the  first  week  or  two  of  the  disease,  and  probably 
in  mcst  instances  begins  to  be  attenuated  after  that  time,  although 
it  may  persist  apparently  in  its  full  strength  over  long  periods  of 
time.  In  the  monkey  the  virus  tends  to  become  fixed,  very  much  in 
the  same  manner  that  the  rabies  virus  becomes  fixed  in  the  rabbit. 
There  are,  however,  some  samples  of  the  virus  that  cannot  be 
intensified  or  fixed.  When  fixed  it  becomes  strongly  virulent,  so 
that  only  very  minute  quantities  are  necessary  to  infect  a  second 
animal.  This  intensity  of  the  fixed  virus  remains  constant  through 
a  long  series  of  animals,  but  eventually,  as  has  been  shown  by 
Flexner,  it  loses  some  of  its  infective  power,  and  in  this  way 
resembles  the  variations  seen  in  difi'erent  epidemics  of  the  disease 
in  human  beings.    There  are  periods  in  which  the  disease  is  epidemic 


VIRUS  IN   THE  HUMAN  BODY  41 

in  which  the  virus  seems  to  be  partieuhirly  ^'i^ule^t,  and  after  a 
certain  time  the  virulence  seems  to  change.  Just  what  brings  about 
this  change  is  not  at  all  understood  at  the  present  time,  but  this 
variation  in  virulence  probably  has  something  to  do  with  the 
recurrence  of  epidemics. 

Further  studies  are  needed  to  determine  the  presence  of  the 
relative  virulence  of  the  virus  as  it  is  found  on  fomites.  The  few 
observations  made  have  merely  demonstrated  that  the  virus  may 
be  found  on  objects  that  have  been  in  intimate  contact  with  patients 
suffering  with  the  disease.  Just  how  long  the  virus  may  be  dried 
under  natural  conditions  before  it  loses  its  virulence  is  at  present 
a  matter  of  question.  Romer,  Flexner  and  Lewis,  Landsteiner  and 
Levaditi  think  that  this  period  is  several  days,  whereas  Wiener  and 
von  Wiesner  believe  that  if  the  material  is  allowed  to  dry  slowly, 
in  a  thin  layer,  it  will  become  non-virulent  in  twenty-four  hours. 
The  more  we  see  of  infectious  diseases  in  general  the  less  impor- 
tance we  attach  to  transmission  by  fomites  as  a  means  of  spreading 
disease,  and  we  think  this  opinion  will  be  borne  out  by  all  who 
have  had  much  practical  experience  with  them. 

Many  studies  have  been  made  on  the  virus  under  artificial  con- 
ditions: for  example,  Landsteiner  and  Levaditi,  and  Pastia^  found 
that  the  virus  lived  at  ordinary  room  temperature  and  light  when 
kept  in  sterile  milk  or  water. 

Flexner  and  Amoss^  have  kept  specimens  of  virus  of  poliomyelitis 
in  the  spinal  cord  and  medulla  of  human  beings  and  monkeys  in 
50  per  cent,  glycerol  at  refrigerator  temperature  for  six  years. 
The  specimens  had  lost  a  part  of  their  activity  and  it  took  larger 
and  repeated  doses  to  produce  infection.  The  tissues  employed  did 
not  show  any  streptococci  or  other  ordinary  bacteria. 

The  Virus  in  the  Human  Body. — At  autopsy  the  virus  may  be 
demonstrated  in  the  tissues  and  secretions  by  inoculated  emulsions 
of  these  into  monkeys.  The  changes  produced  in  the  monkeys  are 
characteristic  and  the  virus  may  be  further  transmitted  to  other 
monkeys  through  large  series  of  animals  covering  long  periods  of 
time.  The  chief  locations  of  the  virus  in  the  body  are  the  central 
nervous  system,  the  brain,  spinal  cord,  and  the  nerves,  and  it  is 
also  found  in  the  lymphatic  system,  chiefly  in  the  mesenteric  nodes. 
It  is  also  found  in  the  tonsils  and  in  the  nasopharyngeal  mucous 
membrane.     It  is  found  less  frequently  in  other  tissues,  and  only 

1  Ann.  de  I'lnst.  Pasteur,  1911,  p.  805. 

2  Jour.  Exper.  Med.,  April  1,  1917,  p.  539. 


42  THE  NATURE  OF  THE  VIRUS 

exceptionally  in  the  blood.  In  the  living  body,  in  those  acutely  ill 
with  the  disease,  it  is  found  in  the  nasopharyngeal  secretions  and 
in  the  washings  from  the  rectum.  It  has  been  demonstrated  in 
this  way  in  the  typical  cases  and  also  in  the  indefinite  and  abortive 
forms.  Kling,  Wernstedt,  and  Pettersson  and  others  have  demon- 
strated it  in  the  mucous  membrane  of  the  nasopharynx  and  rectum 
in  convalescent  patients,  and  it  may  persist  for  weeks  or  even 
months.  Persons  associated  with  cases  of  the  disease,  especially 
in  times  of  epidemics,  may  also  have  the  virus  in  the  nasopharynx 
or  intestinal  tract  without  ever  having  had  any  symptoms  of  the 
disease. 

Curiously  enough  the  virus  has  apparently  never  been  demon- 
strated in  the  cerebrospinal  fluid  of  human  beings.  Flexner  and 
Lewis^  found  the  virus  in  the  spinal  fluid  of  a  monkey  three  days 
after  the  intracerebral  injection  of  the  virus.  Abramson^  reports 
that  during  the  New  York  epidemic  of  1916  cultures  were  made 
from  over  1200  fluids  from  patients  with  acute  poliomyelitis  in  all 
stages  of  the  disease.  Except  for  a  few  evident  contaminations  the 
cultures  remained  sterile.  Observations  on  animals  with  the  fluids 
from  40  patients  also  gave  negative  results.  Nuzum  and  Herzog^ 
report  that  they  found  a  Gram-positive  coccus  in  90  per  cent,  of 
the  fluids  in  cases  of  poliomyelitis.  Further  comment  is  made  on 
their  study  below. 

The  Choroid  Plexus  and  the  Virus. — ^Flexner  and  Amoss^  haxe 
shown  that  the  meningeal  choroid  plexus  is  normally  capable  of 
excluding  from  the  nervous  system  the  virus  circulating  in  the 
blood  and  also  in  preventing  infection  from  the  virus  present  on 
the  nasal  mucosa.  They  have  found  that  normal  monkey  or  horse 
serum,  isotonic  salt  solution,  Ringer's  solution,  and  Locke's  solu- 
tion, when  injected  into  the  meninges,  cause  an  irritation  which 
diminishes  the  protection  of  the  choroid  plexus  and  permits  the 
virus  of  poliomyelitis  introduced  into  the  blood  to  pass  into  the 
central  nervous  system.  Simple  lumbar  puncture,  where  there  has 
been  no  hemorrhage,  does  not  seem  to  have  any  influence  upon  the 
passage  of  the  virus  into  the  central  nervous  system;  but  if  there 
has  been  hemorrhage,  this  seems  to  increase  the  permeability. 
Immune  serum  is  the  only  substance  which  is  not  succeeded  by 
infection  from  the  virus  introduced  into  the. blood.    These  observa- 

1  Jour.  Am.  Med.  Assn.,  April  2,  1910,  p.  1140.  ^  ibid.,  February  17,  1917, 

3  Ibid.,  October  21,  1916,  p.  1205;  Ibid.,  November  11,  1916,  p.  1437. 
^  Jour.  Exper.  Med.,  April  1,  1917,  p.  525. 


NEUTRALIZATION  OF   VIRUS  BY  NASAL  WASHINGS      43 

tions  would  seem  to  be  another  reason  for  using  immune  serum  in 
preference  to  any  of  the  other  substances  suggested. 

The  Virus  Outside  the  Body. — Numerous  studies  have  been  made 
on  this  subject,  and  it  has  been  demonstrated  by  Neustaedter  and 
Thro^  in  the  dust  of  rooms  that  had  been  occupied  by  three  different 
eases.  It  has  also  been  demonstrated  on  handkerchiefs  and  embroid- 
ery work  that  have  been  about  the  patient,  but  comparatively  few 
observations  have  been  made  upon  this  subject.  The  virus  has 
also  been  studied  outside  the  human  body  under  artificial  conditions. 

The  Length  of  Time  the  Virus  Persists.^ — In  the  bodies  of  monkeys 
the  virus  is  found  to  disappear  from  the  central  nervous  system  in 
from  three  to  six  weeks,  but  it  remains  in  the  mucous  membrane 
of  the  nose  and  throat  and  apparently  also  in  the  intestine.  In 
man  the  virus  apparently  grows  rapidly  weaker  after  the  first 
eight  to  fourteen  days,  and  in  most  instances  has  disappeared  com- 
pletely, or  almost  so,  after  a  period  of  three  or  four  weeks;  but  it 
may  persist  much  longer,  and  has  been  demonstrated  in  the  secre- 
tions of  the  mouth  for  six  months  after  the  onset  of  the  disease. 

For  ordinary  purposes  of  isolation  from  six  to  eight  weeks  have 
been  advised,  but  this  will  permit  a  certain  number  of  individuals 
to  go  about  with  a  more  or  less  attenuated  virus  still  present. 
From  practical  observations  in  the  New  York  epidemic  two  weeks 
would  seem  to  us  to  be  a  suitable  isolation  period. 

Neutralization  of  the  Virus  of  Poliomyelitis  by  Nasal  Washings. — 
Amoss  and  Taylor^  have  made  some  interesting  experiments  and 
have  shown  that  the  washings  of  the  nasal  and  pharyngeal  mucosa 
possesses  a  definite  power  to  inactivate  or  neutralize  the  active 
virus  of  poliomyelitis.  This  power  varies  at  different  times  in  the 
same  individual,  and  inflammatory  conditions  of  the  nose  and 
throat  either  diminish  or  inhibit  the  power  of  neutralization  entirely. 
The  neutralizing  substance  is  water-soluble  and  apparently  is 
organic.  Its  action  apparently  does  not  depend  upon  the  presence 
of  mucin  as  such.  They  have  not  made  a  sufficient  number  of 
tests  to  ascertain  whether  adults  and  children  differ  with  respect 
to  the  existence  of  this  neutralizing  property  in  the  nasal  secretions. 
They  suggest  that  it  is  possible  that  the  production  of  healthy  car- 
riers through  contamination  with  the  virus  may  be  determined  by 
the  presence  or  absence  of  this  inactivating  or  neutralizing  property 
in  the  secretions.    This  subject  may  prove  to  be  a  fertile  field  for 

1  New  York  Med.  Jour.,  September  23,  1916,  p.  613;  October  21,  1911,  p.  813. 

2  Jour.  Exper.  Med.,  April  1,  1917,  p.  507. 


44  THE  NATURE  OF  THE  VIRUS 

further  investigation,  and  it  would  be  exceedingly  interesting  to 
have  determined  what  effect  antiseptics  have  on  these  substances. 

The  Cultivation  of  the  Microorganism  Causing  Poliomyelitis. — 
Noguchi/  working  with  Flexner  in  the  Rockefeller  Institute,  has 
succeeded  in  growing  microorganisms  by  the  use  of  Noguchi's 
method  for  cultivating  spirochetes,  the  material  used  being  nerve 
tissue  derived  both  from  human  poliomyelitis  and  also  from  experi- 
mental poliomyelitis  in  monkeys.  The  first  thing  is  to  obtain  the 
nervous  tissue  in  as  early  an  aseptic  condition  as  possible,  and  for 
this  purpose  the  brain  is  to  be  preferred,  because  it  is  more  easily 
separated  from  the  rest  of  the  body  in  a  more  suitable  condition 
than  the  other  portions  of  the  nervous  condition.  Pieces  of  about 
2  c.c.  thickness  are  taken,  and  inoculations  are  made  both  with 
fragments  and,  if  there  is  any  reason  to  suspect  contamination, 
with  filtrates.  The  filtrates  are  made  by  grinding  the  nervous 
tissue  with  sand  in  distilled  water  or  normal  salt  solution.  This 
emulsion  is  then  shaken  in  a  machine  for  about  thirty  minutes, 
centrifugalized,  and  the  supernatant  fluid  through  an  N  or  V 
Berkefeld  filter.  The  culture  medium  used  is  made  of  human  ascitic 
fluid  to  which  has  been  added  a  fragment  of  sterile,  fresh  tissue. 

For  the  initial  cultures  it  is  necessary  to  exclude  oxygen  by  cov- 
ering the  liquid  with  a  deep  layer  of  sterile  paraffin  oil.  It  is  not 
essential  that  the  tubes  be  placed  in  an  anaerobic  jar,  but  it  would 
seem  that  the  initial  growth  is  more  easily  obtained  when  this  is 
done.  The  tubes  for  the  cultures  measure  1.5  by  20  c.c,  and  in 
ea3h  oi  these  is  pla3»d  a  fragment  of  sterile  rabbit  kidney  and  a 
fragment  of  an  equal  size  of  nervous  tissue.  Upon  these  are  poured 
about  15  c.c.  of  sterile  ascitic  fluid,  and,  finally,  about  4  c.c.  of 
sterile  paraffin  oil.  The  ascitic  fluid  must  be  originally  sterile,  as 
sterilization  either  by  fractional  heating  or  filtration  renders  it 
unsuitable.  The  experiment  is  controUed  by  other  tubes  contain- 
ing kidney  and  ascitic  fluid  and  brain  and  ascitic  fluid;  two  sets 
should  be  prepared,  one  of  which  is  to  be  placed  in  an  anaerobic 
jar  and  the  other  kept  outside,  but  both  are  to  be  cultivated  at  the 
ordinary  thermostat  temperature,  namely,  37°  C.  The  tubes  in 
the  jars  are  not  disturbed  for  from  seven  to  twelve  days.  Those 
outside  may  be  inspected  daily.  If  within  one  or  two  days  there  is 
turbidity,  coagulation,  or  gas-production  the  tubes  may  be  dis- 
carded as  being  grossly  contaminated.     Small  quantities  of  the 

1  Jour.  Am.  Med.  Assn.,  Ix,  362;  Jour.  Exper.  Med.,  October  1,  1913,  p.  462. 


MICROORGANISM  CAUSING  POLIOMYELITIS  45 

medium  are  removed  with  pipettes  and  stained  for  bacteria  in  the 
ordinary  way  and  cultivated  upon  the  usual  solid  or  fluid  media. 
If  the  clear  tubes  show  organisms,  they  may  also  be  discarded. 
In  the  other  tubes,  at  the  expiration  of  about  five  days,  there  is  an 
opalescence  about  the  organisms  at  the  bottom  of  the  tube.    This 
may  be  gradually  diffused  throughout  the  tube  by  gentle  shaking. 
The  control  tubes,  when  not  contaminated,  either  remain  perfectly 
clear  or  have  a  slight  granular  precipitate  of  washed-out  granules 
of  tissue  about  them.    In  from  three  to  five  days  the  opalescence 
extends  into  the  upper  portions  of  the  medium,  while,  in  the  control 
tubes,  the  precipitate  gathers  more  and  more  at  the  lower  end  of 
the  tubes.    After  ten  to  twelve  days  the  diffuse  opalescence  dimin- 
ishes and  small  particles  of  it  begin  to  fall  slowly  to  the  bottom  of 
the  tube.    The  tubes  in  the  anaerobic  jar  on  the  seventh  day  show 
a  similar  growi:h,  but  somewhat  less  marked.    At  the  end  of  five  or 
six  days  the  appearance  is  very  much  that  of  the  tubes  that  have 
been  kept  in  the  air  for  one  week.    The  organism  may  also  be  cul- 
tivated on  a  solid  medium  consisting  of  ascitic  fluid  and  sterile 
rabbit  tissue  to  which  a  suitable  culture  of  2  per  cent,  nutrient  agar 
has  been  added  in  order  to  produce  a  solid  mixture.    This  is  not 
suitable  for  the  initial  growth,  but  once  the  culture  has  been  secured 
in  the  fluid  medium  it  is  possible  sometimes,  but  not  always,  to 
transmit  it  to  the  solid  medium.    It  is  possible  to  secure  cultivation 
even  in  the  absence  of  the  rabbit  tissue,  and  for  this  purpose  a 
somewhat  larger  fragment  of  nerve  tissue  is  used.    The  experiment 
is  less  apt  to  succeed,  however,  than  when  the  rabbit  tissue  is  used. 
Other  fluid  culture  media  have  also  been  used,  consisting  of  sheep 
serum  water  or  an  extract  prepared  from  the  brain  tissue,  but 
neither  of  these  are  suitable  without  the  addition  of  rabbit  tissue, 
and  they  are  not  as  useful  in  studying  the  organism.    Glycerinated 
fragments  of  nervous  tissue  kept  in  50  per  cent,  glycerin,  at  a 
temperature  of  from  2°  to  4°  C.  for  periods  varying  from  twenty- 
five  days  to  one  year,  were  also  used,  and  the  resulting  growths, 
when    they    occurred,  produced    the    characteristic    appearances 
already  noted.     In  33  experiments  an  initial  growth  was  obtained  in 
19  instances,  16  of  which  proved  to  be  pure  and  3  were  mLxed  with 
other  organisms.     Of  these,  pure  subcultures  were  obtained   13 
times,  and  in  many  of  these  the  subcultures  were  maintained  alive 
for  an  indefinite  period.    The  fluid  cultures,  under  the  dark-field 
microscope,  show  globular  bodies  of  very  small  size  which  hang 
together  in  small  chains,  parts,  or  in  small  masses.    They  are  devoid 


46  THE  NATURE  OF  THE  VIRUS 

of  the  independent  motility  and  difficult  to  separate  from  the  numer- 
ous small,  moving  granules  which  are  always  present.  The  stain 
preparations  bring  these  small  bodies  out  plainly.  The  organisms 
may  be  stained  either  by  the  method  of  Giemsa  or  by  Gram's 
method,  but  in  either  case  the  staining  is  accomplished  with  more 
or  less  difficulty. 

From  the  fact  that  the  microorganism  described  was  so  con- 
stantly found  in  the  central  nervous  system  of  both  human  beings 
and  monkeys  infected  with  poliomyelitis  it  was  strongly  presump- 
tive that  it  bore  a  very  close  relation  to  the  disease.  Two  series 
of  inoculations  were  made  into  Macacus  rhesus  monkeys,  one  being 
from  cultures  derived  from  human  beings  and  the  other  from 
monkeys.  The  cultures  were  inoculated  into  the  brain  or  into  the 
sciatic  nerve  or  peritoneal  cavity  simultaneously.  It  was  possible 
to  produce  in  monkeys  typical  poliomyelitis  which  showed  typical 
lesions  at  autopsies,  and  from  which,  in  some  instances,  the  cul- 
tures could  again  be  recovered.  The  microorganism  can  be  detected 
in  film  preparations  and  in  sections  prepared  from  the  central 
nervous  system  of  human  beings  who  had  died  of  poliomyelitis, 
and  from  monkeys  in  which  the  disease  had  been  produced  experi- 
mentally. It  will  not  be  necessary  to  go  into  the  technic  which  was 
devised  by  Noguchi  for  demonstrating  these,  the  details  of  which 
are  given  in  the  articles  from  which  these  extracts  have  been  made. 

These  microorganisms  are  very  small,  measuring  from  0.15 
to  0.3  micron  in  diameter.  They  are  grown  under  conditions 
which  are  favorable  to  the  growth  of  bacteria,  but  the  observers 
at  present  have  no  opinion  to  offer  as  to  the  place  which  these 
organisms  occupy  among  living  things.  Whether  the  organism  is 
a  bacterium  or  a  protozoan  has  not  been  determined.  What  is 
known  is  that  it  passes  through  a  Berkefeld  filter,  that  it  is  capable 
of  recultivation,  apparently  indefinitely,  and  that  the  organism  is 
identical  whether  derived  from  human  sources  or  monkeys.  Great 
difficulties  are  experienced  in  obtaining  the  initial  culture,  and  it  is 
not  always  possible  to  demonstrate  the  organism;  even  when  the 
organism  is  grown  it  may  not  possess  a  sufficient  degree  of  patho- 
genicity to  cause  an  infection  in  the  monkey.  It  is  possible  that 
there  are  two  factors  present  in  the  culture — one  invisible  and  the 
other  the  globular  bodies  described. 

As  far  as  we  know  this  work  has  not  been  very  largely  confirmed 
by  other  observers,  but,  on  the  other  hand,  there  has  been  nothing 
done  to  contradict  it  unless  it  is  the  work  mentioned  below. 


INVESTIGATIONS   OF  THE  CULTIVATION  OF  THE  VIRUS      47 

The  Bacteriology  of  Poliomyelitis. — The  earlier  investigations  on 
the  bacteriology  of  poHomyehtis  were  largely  limited  to  the  finding 
of  diplococci  or  micrococci  in  the  cerebrospinal  fluid.  Biilow- 
Hansen  and  Ilarbitz^  isolated  a  diplococcus  from  acute  cases,  and 
Harbitz  and  ScheeP  confirm  their  observations.  Geirsvold^  found 
a  diplococcus  in  12  cases  and  claims  to  have  caused  paralysis  and 
death  by  inoculation  into  animals.  Pasteur,  Foulerton  and  Mac- 
cormac*  found  a  micrococcus  in  the  fluid  which,  when  inoculated 
into  rabbits  produced  a  disease  condition  similar  to  that  seen  in 
human  beings.  Similar  observations  were  made  by  Dixon  and  Fox 
in  the  Pennsylvania  epidemic  of  1907,  and  they  found  a  diplococcus 
not  only  in  the  cerebrospinal  fluid,  but  also  in  the  nose  and  throat 
of  patients  suffering  with  acute  attacks  of  the  disease,  and  Rucker^ 
studied  this  diplococcus,  which  would  seem  to  be  similar  to  that 
described  below  in  the  consideration  of  the  recent  investigations. 

Recent  Investigations  of  the  Cultivation  of  the  Virus. — Several 
articles  have  appeared  recently  dealing  with  this  subject,  the  first 
by  Mathers,^  the  second  by  E.  C.  Rosenow,  Towne  and  Wheeler,^ 
and  the  third  by  Nuzum  and  Herzog.^  All  these  articles  deal 
with  the  cultivation  of  a  micrococcus.  Mathers  used  the 
material  from  the  brain  and  cord  obtained  at  autopsy  under 
sterile  conditions,  and  as  soon  after  death  as  possible,  and  inocu- 
lated it  into  the  various  mediums,  as  ascites  fluid  and  ascites- 
dextrose  agar  containing  a  small  piece  of  rabbit  kidney,  ascites- 
dextrose  broth,  and  coagulated  with  normal  horse  serum.  The 
cultures  were  made  both  aerobically  and  anaerobically,  and  were 
incubated  at  35°  C.  for  from  one  to  seven  days.  In  7  of  8  cases, 
after  thirteen  hours  in  aerobic  cultures,  and  in  from  three  to  seven 
days  in  anaerobic  cultures,  a  Gram-positive  micrococcus  was 
obtained,  and  in  6  of  these  the  organism  was  in  pure  culture.  Cul- 
tures from  the  heart  blood  and  from  the  cerebrospinal  fluid  after 
death  did  not  show  the  organism,  but  it  was  demonstrated  in  the 
mesenteric  Ijinph  nodes.  It  is  of  low  virulence  for  rabbits,  but 
when  injected  into  the  veins  in  large  doses,  lesions  of  the  central 
nervous  system  are  produced,  with  paralysis,  particularly  of  the 

1  Norsk.  Mag.  Laegevidensk.,  1898,  xiii,  1170. 

2  Jour.  Am.  Med.  Assn.,  1908,  1,  281;  ibid.,  xlix,  1420. 

3  Norsk  Mag.  Laegevidensk.,  1905,  p.  1280. 

4  Arch,  for  Middlesex  Hospital,  London,  1908,  xii,  208;  Lancet,  1908,  p.  484. 

5  Reports  of  the  Health  Department  of  Pennsylvania,  1907,  p.  420. 

6  Jour.  Am.  Med.  Assn.,  September  30,  1916,  p.  1019. 

'  Ibid.,  October  21,  1916,  p.  1202.  8  ibid.,  p.  1205. 


48  THE  NATURE  OF   THE  VIRUS 

extremities.  Intracerebral  injections  into  a  monkey  also  caused 
paralysis.  After  three  or  four  transfers  on  artificial  mediums,  the 
organism  seems  to  lose  its  affinity  for  the  nervous  system. 

Rosenow,  Towne  and  Wheeler  made  a  study  of  the  throats,  ton- 
sils, spinal  fluid,  blood,  central  nervous  system  and  other  tissues, 
and  isolated  a  peculiar  polymorphous  streptococcus  from  the 
throat  and  tonsils,  and  from  abscesses  in  the  tonsil  in  a  large  series 
of  cases  of  epidemic  poliomyelitis.  They  also  obtained  it  from  the 
ventricular  fluid  after  death  and  from  the  blood  in  one  instance,  but 
not  from  the  spinal  fluid.  Their  organism  was  apparently  the  same 
as  that  of  Mathers. 

The  cocci,  when  grown  under  anaerobic  conditions,  has  a  tendency 
to  become  very  small,  and  suggested  the  globoid  bodies  described 
by  Flexner  and  Noguchi,  and  the  smallest  of  these  could  be  filtered 
through  Berkefeld  filters,  while  the  larger  ones  could  not.  It  is 
now  suggested  that  the  globoid  forms  described  by  both  authors 
may  be  due  to  the  breaking  down  of  some  of  the  larger  diplococcus 
forms. 

BulP  has  made  a  study  of  streptococci  cultivated  from  the  ton- 
sils of  32  cases  of  poliomyelitis,  and  observations  were  made  on 
guinea-pigs,  dogs,  cats,  rabbits,  and  monkeys.  In  no  case  was 
anything  induced  resembling  poliomyelitis,  either  clinically  or 
pathologically,  but  some  of  the  animals  developed  lesions  ordi- 
narily seen  in  streptococcus  infection.  These  lesions  did  not  seem 
to  vary  in  character  or  frequency  from  those  caused  by  streptococci 
from  other  sources.  The  monkeys  whi?h  had  recovered  from 
infection  from  streptococci  from  poliomyelitis  did  not  show  any 
protection  from  infection  with  the  filtered  virus,  and  their  blood 
did  not  neutralize  the  filtered  virus  in  vitro.  These  observations 
may  be  taken  distinctly  against  the  idea  that  poliomyelitis  is  caused 
by  a  streptococcus,  and  it  is  also  a  fact  that  the  thousands  of  cases 
seen  in  New  York  in  the  summer  of  1916,  in  which  there  was  no 
instance  of  metastatic  infection  and  inflammation,  such  as  are 
ordinarily  seen  in  streptococcus  infection. 

Another  recent  study  has  been  made  by  Kolmer,  Brown  and 
Freese.2  They  found  that  in  cases  of  acute  poliomyelitis  that  four 
different  kinds  of  microorganisms  could  be  grown  without  diffi- 
culty. These  were  streptococci,  diplococci,  diphtheroid  bacilli,  and 
Gram-negative  bacilli.    The  streptococci  were  found  to  be  grown 

1  Jour.  Exper.  Med.,  April  1,  1917,  p.  557.  ^  ibid.,  June  1,  1917,  p.  789. 


VIRUS  IN  MONKEYS  49 

both  aerobically  and  anaerobically,  and  under  the  latter  conditions 
the  organisms  l)ecame  small  and  round,  and  they  were  more  easily 
decolorized  with  alcohol  in  the  Gram  stain  than  the  others.  1'hese 
organisms  were  not  found  in  the  cerebrospinal  fluid  in  10() 
different  observations,  but  they  were  found  in  one  of  20 
anerobic  blood  cultures,  and  in  fatal  cases  were  easily 
isolated  from  the  nervous  tissue,  tonsils,  liver,  lungs,  kidneys, 
spleen,  pancreas,  thymus  gland,  suprarenal  glands,  and  mesenteric 
lymph  nodes.  The  diplococci  were  Gram-positive,  and  when  trans- 
planted to  solid  media  grew  abundantly  and  looked  like  a  staphy- 
lococcus that  grew  both  aerobically  and  anaerobically,  and  under 
the  latter  conditions  the  growth  was  slow  and  the  cocci  became 
small  and  round.  They  found  these  organisms  in  48  out  of  lOG 
cerebrospinal  fluids,  and  also  in  the  nervous  tissue  and  organs 
mentioned  above.  These  organisms  did  not  produce  any  paralytic 
conditions  either  in  rabbits  or  in  monkeys,  but  the  streptococci  set 
up  arthritis  and  meningitis.  These  organisms  are  apparently  sec- 
ondary to  the  real  cause  of  poliomyelitis,  or  else  are  terminal  infec- 
tions. Perhaps  the  chief  reason  for  doubting  that  the  streptococci 
are  the  cause  of  poliomyelitis  is  that  where  they  have  produced 
lesions  in  the  nervous  system  they  have  done  so  in  animals  that 
have  ordinarily  been  found  refractory  to  the  virus  of  poliomyelitis 
obtained  by  ordinary  methods.  It  is  well  known  that  almost  any 
organism  injected  into  an  animal  will  find  its  way  into  the  nervous 
system  and  cause  lesions,  providing  the  animal  is  not  killed  too 
promptly  by  the  germ  and  the  amount  injected  is  sufficient.  Until 
we  have  evidence  of  a  much  more  convincing  nature  than  that 
given  up  to  date,  we  believe  it  is  pretty  safe  to  state  that  these 
organisms  are  not  the  causal  agent  of  the  disease. 

The  Transmission  to  Animals. — The  only  animal  that  may  be 
satisfactorily  inoculated  at  the  present  time  is  the  monkey,  although 
rabbits  under  certain  conditions,  as  given  below,  seem  to  be  subject 
to  the  disease,  and  possibly,  exceptionally,  guinea-pigs.  Up  to  the 
present  time  it  has  not  been  possible  to  produce  the  disease  in  any 
of  the  other  animals  that  have  been  used  for  observations,  including 
dogs,  cats,  horses,  goats,  sheep,  and  some  of  the  other  familiar 
small  animals. 

The  Virus  in  Monkeys. — The  disease  may  be  transmitted  by  inject- 
ing the  virus  into  the  brain,  subdural  spaces,  or  the  nerves,  into  the 
peritoneal  cavity,  and  less  easily  by  injecting  it  subcutaneously, 
and  much  less  so  by  injecting  it  into  the  general  circulation.  It 
4 


50  THE  NATURE  OF   THE   VIRUS 

may  also  be  transferred  by  rubbing  it  into  the  scarified  or  healthy 
pharyngeal  mucous  membrane.  It  may  also  be  transmitted  by 
way  of  the  stomach  or  intestines,  but  only  by  using  massive  doses 
of  the  virus.  The  virus  for  experimental  purposes  usually  consisted 
of  emulsions  of  the  various  tissues  mentioned,  either  used  as  such 
or  after  filtration  through  a  Berkefeld  filter. 

The  disease  in  the  monkey  is  typical,  though  not  quite  identical, 
with  that  seen  in  human  beings.  The  experimental  work  done 
upon  monkeys  seems  to  point  to  the  fact  that  the  disease  may  be 
transmitted  under  natural  conditions  through  the  nasopharynx  or 
through  the  digestive  tract.  This  question  of  transmission  will  be 
considered  under  the  subheading. 

Virus  in  the  Guinea-pig. — Whether  or  not  guinea-pigs  are  suscep- 
tible to  the  disease  is  a  matter  of  some  question.  Romer  and  Joseph 
were  unable  to  transfer  the  virus  from  monkeys  to  guinea-pigs, 
but  they  observed  that  guinea-pigs  kept  in  the  laboratory  occa- 
sionally died  from  a  paralytic  disease,  and  Romer,  studying  this, 
found  that  it  was  apparently  due  to  a  filtrable  virus.  More  recently 
Neustaedter^  claims  to  have  transferred  the  virus  from  a  guinea- 
pig  to  another  guinea-pig  and  back  again  to  a  monkey,  the  guinea- 
pig  having  presumably  been  infected  in  the  first  instance  through 
contact  with  a  monkey  with  the  disease.  Rosenau  and  Havens 
inoculated  a  few  guinea-pigs,  and  those  that  died  showed  lesions 
somewhat  like  the  ones  described  in  rabbits.  They  do  not  consider 
that  their  observations  are  sufficiently  advanced  at  this  time  to 
draw  conclusions. 

The  Virus  in  Rabbits. — There  have  been  various  statements  made 
concerning  the  susceptibility  of  rabbits  to  the  virus  of  this  disease. 
Krause  and  Meinicke,^  in  1909,  were  the  first  to  pass  the  virus 
obtained  from  a  human  being  through  seven  generations  in  rabbits, 
and  the  following  year  Lents  and  Huntemiiller''  were  able  to  pro- 
duce the  disease  by  using  the  virus  from  one  rabbit  to  another  by 
several  methods  of  inoculation,  but  the  lesions  in  the  brain  and 
spinal  cord  were  not  as  marked  as  those  found  in  monkeys.  Vari- 
ous other  observers,  as  Romer  and  Joseph,^  Landsteiner  and  Leva- 
diti,^  Leiner  and  von  Wiesner,^  and  Flexner  and  Lewis^  were  all 

1  Jour.  Am.  Med.  Assn.,  1913,  Ix,  982. 

2  Deutsch.  med.  Wchnschr.,  1909,  xxxv,  1825. 

2  Ztschr.  f.  Hyg.  u.  Infectionkrankh.,  1910,  Ixvi,  481. 

4  Munchen.  med.  Wchnschr.,  1910,  Ivii,  2685. 

5  Compt.  rend.  soc.  de  biol.,  1909,  Ixvii,  787. 

fiWien.  klin.  Wchnschr,,  1909,  xjcii,  1698.        '  Jour.  Exper.  Med.,  1910,  xii,  227. 


VIRUS  IN  INSECTS  51 

unable  to  transfer  the  disease  to  rabbits.  Marks/  using  virus  from 
a  monkey,  passed  the  (Hsease  throu<i;h  seven  generations  of  young 
rabbits.  Those  that  died  had  convulsions,  but  did  not  develop 
any  paralysis.  He  could  not  find  any  definite  lesions  which  were 
characteristic  of  poliomyelitis  on  microscopic  examination,  and  he 
further  stated  that  it  was  not  possible  to  transfer  all  strains  of 
virus  successfully  to  rabbits.  Rosenau  and  Havens,-  using  the  virus 
from  a  monkey,  succeeded  in  passing  the  disease  through  eight 
generations  of  rabbits,  and  at  the  time  of  the  report  the  virus  shows 
no  sign  of  dying  out;  and  indeed,  it  seemed  to  be  becoming  more 
pathogenic  with  each  successive  passage. 

The  Virus  in  Insects. — The  seasonal  occurrence  of  the  disease 
and  the  difficulty  of  explaining  certain  facts  in  the  epidemiology  of 
the  disease  has  suggested  that  the  disease  might  be  transmitted  by 
insects,  and  at  one  time  it  was  thought  that  the  ordinary  biting 
stable  fly,  Stomoxys  calcitrans,  might  be  responsible  for  the  trans- 
mission of  the  disease.  The  experiments  of  Rosenau  along  this 
line  have  not  been  confirmed  by  other  observers,  and  it  seems  quite 
certain  that  the  disease  is  not  harbored  in  the  bodies  of  flies,  nor, 
indeed,  as  far  as  we  know  at  the  present  time,  by  any  of  the  ordi- 
nary insects  found  about  cases.  It  seems  highly  probable,  however, 
that  the  ordinary  fly  might  be  a  factor  in  acting  as  passive  carriers 
of  the  virus,  as  Flexner  and  Lewis  and  other  observers  have  found 
that  a  fly  soiled  with  the  virus  remains  a  source  from  which  the 
virus  may  be  recovered  for  at  least  forty-eight  hours  in  certain 
instances.  One  can  readily  understand  how  a  fly  soiled  with  the 
nasal  secretions  of  a  sick  child  might  transfer  the  disease  by  crawl- 
ing over  the  face  of  a  well  child,  and  until  the  insect  methods  of 
transmission  are  better  understood,  flies  should  be  rigidly  excluded 
from  the  sick  rooms  of  cases  of  poliomyehtis.  (See  also  the  Rat 
and  Poliomyelitis.) 

1  Jour.  Exper.  Med.,  1911,  xiv,  116. 

2  Ibid.,  1916,  xxiii,  461. 


CHAPTER  V. 
EPIDEMIOLOGY. 

It  is  interesting  to  note  the  growth  of  our  conception  of  polio- 
myelitis as  an  epidemic  disease.  At  first,  in  spite  of  certain  small 
epidemics,  the  possibility  of  contagion  was  not  considered.  Then 
came  the  period  in  which  Medin  demonstrated  conclusively  that 
the  disease  occurred  in  epidemic  form.  This  only  took  into  account, 
however,  the  cases  that  were  frankly  paralyzed.  Wickman,  in 
1904,  pointed  out  the  fact  that  the  disease  could  occur  in  a  non- 
paralytic, or  the  so-called  abortive  form,  and  never  show  any  evi- 
dence of  paralysis,  and  that  these  cases  may  have  a  great  deal  to 
do  with  the  spread  of  the  disease.  Then  the  idea  grew  that  the 
disease  was  not  an  exceptional  one,  but  one  that  was,  in  reality, 
very  common,  and  that  perhaps  a  very  large  proportion  of  the  pop- 
ulation had  at  some  time  or  other  been  afflicted  with  it  without 
the  production  of  paralysis  and  were  so  immune.  As  in  the  case 
of  a  number  of  infections,  it  seems  highly  probable  that  the  disease 
may  occur  in  a  slight  form,  particularly  in  the  first  few  years  of 
life.  This  conception  of  the  disease  needs  further  study  to  confirm 
it,  but  certainly  the  facts  that  have  been  brought  to  light  in  recent 
observations  have  shown  nothing  to  the  contrary. 

The  question  arises  as  to  whether  the  disease  as  it  is  seen  in 
America  has  taken  on  a  special  infectivity  of  recent  years  or  whether 
the  virus,  for  some  reason  or  other,  has  increased  in  virulence  with 
a  greater  tendency  to  involve  the  nervous  system.  There  is  also 
the  question  of  importation  of  the  virus,  and  there  are  some  who 
believe  that  a  fresh  virus  may  have  been  imported  in  the  Scandi- 
navian immigrants  along  and  after  the  time  of  the  epidemic  of  1905 
in  Norway  and  Sweden.  Some  42,000  Scandinavians  arrived  as 
immigrants  in  the  United  States  about  1907,  and  it  is  possible  that 
a  fresh  and  more  vigorous  virus  was  introduced  into  this  country. 
The  geographical  distribution  of  poliomyelitis  in  1907  in  the  Middle 
West  did  not,  however,  correspond  closely  with  the  distribution  of 
the  Scandinavian  immigrants.  It  seems  highly  probable  that  if  a 
fresh  and  vigorous  virus  were  imported,  that  a  larger  proportion 
of  adults  would  have  been  affected,  as  it  is  well  known  that  wherever 


FREQUENCY  OF  THE  DISEASE  53 

a  disease  is  freshly  imported  into  a  country  in  which  a  relative 
immunity  has  not  been  produced  by  many  generations  having  had 
the  disease  that  it  affects  all  ages  of  the  population.  Thus,  measles 
ordinarily  is  a  disease  of  the  first  decade  of  life,  hut  when  intro- 
duced into  the  Faroe  Islands,  where  it  had  not  been  for  over  a  gen- 
eration, it  attacked  a  very  large  proportion  of  the  inhabitants  of 
all  ages. 

The  Geographical  Distribution. — In  Norway  there  was  a  small 
epidemic  noted  in  1868,  and  in  Sweden  the  first  epidemic  was  appar- 
ently in  1881.  Since  that  time  epidemics  have  become  more  and 
more  frequent,  and  since  the  big  epidemic  of  1905  the  disease  has 
been  reported  in  more  or  less  devastating  epidemics  throughout 
Europe,  the  United  States,  the  West  Indies,  South  America,  Aus- 
tralia, and  the  South  Sea  Islands.  In  Europe  it  extends  from 
Scandinavia  to  the  Mediterranean  and  from  the  British  Isles  at 
least  to  the  Danube,  and  perhaps  much  farther.  The  disease  is 
endemic  throughout  these  areas,  a  certain  number  of  cases  in  every 
State  and  practically  every  large  city,  and  this  has  been  true  for 
a  great  mam'  years,  although  not  much  attention  has  been  paid 
to  the  disease  by  health  departments  until  very  recently.  All  the 
earlier  epidemics  were  apparently  small  and  scattered,  and  at 
the  time  did  not  attract  very  much  attention.  Since  1905  a  very 
considerable  amount  of  attention  has  been  paid  to  the  disease,  and 
in  the  last  few  years  a  very  great  prominence  given  to  it  in  the 
public  press.  A  list  of  the  epidemics  will  be  found  in  another 
place. 

The  Frequency  of  the  Disease. — It  depends  somewhat  on  what 
one  includes  as  poliomyelitis  as  to  the  number  of  cases  that  wdll  be 
included  in  any  set  of  statistics.  Emers6n^  estimates  that  since  the 
early  summer  of  1916  there  have  been  24,000  cases  of  poliomye- 
litis in  the  United  States,  and  that  18,000  of  these  were  in  New 
York  City  and  the  adjacent  territory  and  the  States  of  New  York, 
New  Jersey,  Pennsylvania,  Connecticut  and  Massachusetts.  In 
the  registration  area  of  the  United  States  in  the  five  years  from  1910 
to  1914  there  were  over  5000  deaths  from  poliomyelitis,  and  a  con- 
servative estimate  as  suggested  in  the  report  of  the  New  \ork 
Board  of  Health  of  the  epidemic  of  1916  places  the  probable  num- 
ber of  cases  at  30,000.  From  June  to  November,  1916,  in  the  regis- 
tration area  there  were  27,000  cases  reported  with  6000  deaths. 

1  Bull.  Johns  Hopkins  Hosp.,  April,  1917,  p.  131. 


54 


EPIDEMIOLOGY 


We  should  like  to  emphasize  the  fact  that  we  believe,  along  with 
almost  all  the  others  who  have  studied  the  disease,  that  at  the 
present  time  most  of  the  non-paralytic  cases  escape  recognition, 
and  indeed  a  very  large  number  of  the  frankly  paralytic  cases  are 
not  diagnosed.  The  New  York  epidemic  of  1907  was  practically 
not  noticed  until  after  the  acute  stage  was  over,  when  the  large 
number  of  cases  applying  to  the  dispensaries  and  the  nerve  special- 
ists for  treatment  led  to  a  thorough  investigation,  with  the  splendid 
report  which  was  made  through  the  New  York  Department  of 


"T" 


"I  r-'-'  '- 


9000 
8000 
7000 
6000  [ 


5000  u. 
o 

4000  liJ 


3000: 


3000 


1000 


-189i-1901-^" 02  'Oi  "00  'OS  '10 


-* 1881-1893 

Fig.  13. — Relative  prevalence  of  infantile  paralysis  in  the  United  States  and 
Europe  and  Australia,  1881-1910.  The  soUd  black  line  refers  to  the  United  States; 
the  dotted  line  to  the  foUomng  countries:  Italy,  Sweden,  Norway,  Germanj^ 
Austria,  France,  England,  and  AustraUa.  Part  of  this  increase  is  due  to  better 
recognition.  In  1916  the  solid  line  would  be  three  times  the  length  shown  in  the 
cut.     (Lovett.) 


Health.  In  spite  of  the  widespread  publicity  given  to  the  disease, 
both  in  the  medical  publications  and  in  the  lay  press,  one  meets 
with  a  large  number  of  cases  in  which  the  diagnosis  does  not  seem 
to  have  even  been  suspected.  For  example,  we  have  recently  seen 
an  instance  of  a  child  referred  on  account  of  pain  in  the  toes.  The 
child  had  a  definite  paralysis  of  some  of  the  muscles  of  one  leg, 
limped  on  walking,  and  the  mother  gave  a  clear  history  of  an  acute 
attack  during  the  previous  summer  with  an  initial  loss  of  power  of 
both  legs,  which  was  recovered  from  in  about  six  weeks'  time.  The 
child  was  seen  by  a  physician,  who  made  a  diagnosis  of  food  poi- 


SEASO^f 


55 


soiling  on  account  of  the  vomiting,  prostration,  and  delirium  at 
the  onset,  and  in  spite  of  tlie  father's  suggesting  the  possibiHty  of 
poHomyeHtis,  the  true  nature  of  the  disease  was  apparently  not 
suspected.  Such  cases  could  be  multiplied  by  very  little  investi- 
gation. It  seems  highly  j)r()bable  that  a  great  number  of  slight 
cases  of  deformities  of  the  feet  and  weaknesses  of  the  muscles  of  the 
legs  are  due  to  unrecognized  cases  of  the  disease.  We  have  seen 
several  well-marked  instances  where  this  seems  to  be  the  case, 
although  the  child  was  not  seen  during  the  acute  sta^e  of  the  disease. 


Fig.  14. — Chart  showing  the  course  of  the  epidemic  of  1916  in  Newark,  X.  J. 
(From  the  Public  Health  Reports  of  the  United  States  Public  Health  Se^^-ice,  Dec. 
8,  1916.) 

Season. — Sinkler^  was  one  of  the  first  to  comment  upon  the 
season  of  the  year  and  its  relation  to  the  disease.  He  studied  270 
cases  and  found  that  78. 8  per  cent,  occurred  in  the  dry  months  of 
the  year — that  is,  from  May  to  September.  This  has  been  the 
experience  of  most  observers  and  of  most  epidemics.  The  disease 
ma}',  however,  occur  in  any  month  of  the  year,  either  sporadically 
or  in  epidemics,  but  there  is  a  marked  preference  for  late  summer 
and  early  autumn,  and  the  least  incidence  is  always  in  the  winter 
and  early  spring.  Wickman  reported  an  epidemic  in  Sweden  last- 
ing through  the  winter  with  its  maximum  in  April  and  IMay.  In 
the  southern  hemisphere  the  disease  occurs  in  the  same  season 


1  Am.  Jour.  Med.  Sc,  April,  1S75. 


56  EPIDEMIOLOGY 

corresponding  to  those  in  the  northern  hemisphere,  but  naturally 
in  different  months  of  the  year.  The  disease  also  seems  to  have  a 
somewhat  greater  preference  for  dry  weather,  although  epidemics 
have  been  noted  during  rainy  seasons.  The  seasonal  preference 
of  the  other  contagious  diseases  varies.  One  sees  pertussis  with 
its  highest  incidence  in  the  late  spring  and  early  summer  almost 
coinciding  to  the  diarrheal  curve,  while  diseases  due  to  stomach 
and  intestinal  disturbances  are  more  common  in  early  fall,  diarrheal 
diseases  and  typhoid  fever  being  examples.  Respiratory  infections 
are  more  common  in  winter,  with  the  exception  of  pertussis  and 
diseases,  in  which  the  infection  is  due  to  direct  contact,  such  as 
smallpox  and  measles,  which  are  more  common  in  winter  than  at 
any  other  time  of  the  year. 

The  Transmission. — The  exact  method  of  transmission  of  the  dis- 
ease under  natural  conditions  is  not  definitely  known  at  this  time. 
The  possibilities  are  by  direct  contact,  by  carriers,  by  dust,  by 
infected  fomites,  as  clothing,  etc.,  by  foodstuffs,  by  insects,  or  by 
domestic  animals.  These  are  considered  more  at  length  below, 
but  we  think  that  one  can  certainly  rule  out,  without  very  much 
discussion,  transmission  by  dust,  by  infected  fomites,  or  by  food- 
stuffs. There  remains  the  question  of  direct  contact  and  carriers 
on  the  one  hand  and  the  disease  being  carried  by  domestic  animals 
or  insects  on  the  other.  Wickman  expressed  the  idea  that  the 
disease  is  transmitted  from  person  to  person,  and  the  facts  in 
favor  of  this  are  very  strongly  presented  by  Kling  and  Levaditi.^ 
This  view  of  the  disease  has  been  pretty  generally  accepted  as  a 
working  basis  by  health  departments  and  by  most  of  the  writers  on 
the  disease.  The  chief  exponents  in  this  country  of  the  direct 
contact  theory  are  the  workers  of  the  Rockefeller  Institute.  The 
evidence  in  favor  of  this  idea  is  the  fact  that  the  virus  has  been 
demonstrated  in  the  secretions  of  the  nose  and  throat  and  in  the 
mucous  membrane  of  the  nose  and  throat,  and  that  by  using  this 
material  the  disease  may  be  reproduced  in  monkeys  by  rubbing 
on  either  the  injured  or  uninjured  nasal  mucosa.  The  virus  has 
also  been  demonstrated  in  the  noses  and  throats  of  individuals  who 
have  been  about  the  acute  cases  of  the  disease  by  observations  on 
animals.  In  some  ways  the  disease  resembles  cerebrospinal  fever, 
which  occurs  in  sporadic  cases  most  of  the  time,  but  under  the 
influence  of  factors  at  present  unknown  may  take  on  an  epidemic 

lAnnales  de  I'lnstitut  Pasteur,  xxvii,  718. 


TRANSMISSION  57 

character  of  greater  or  less  severity.  The  germs  are  found  in  the 
nasal  secretions,  and  are  aj)parently  transmitted  either  by  (Hrect 
contact  with  cases  or  by  carriers.  The  mere  fact  that  the  disease 
can  be  transmitted  experimentally  in  this  way  must  not  be  taken 
as  absolute  proof  that  it  is  always  transmitted  thus  under  natural 
conditions.  There  is,  it  is  true,  the  report  of  one  small  epidemic 
in  the  town  of  Stotboken,  off  the  coast  of  Norway,  where  Kling 
and  Levaditi  found  that  owing  to  the  small  number  of  people  it 
was  possible  to  trace  the  transference  of  the  disease  from  case  to 
case.  This  is,  as  far  as  we  know,  the  only  epidemic  of  this  kind 
reported,  but  it  is  seldom  that  circumstances  are  met  with  that  the 
intermingling  of  people  is  not  too  great  to  trace  the  spread  of  the 
disease.  Against  this  idea  is  the  fact  that  the  disease  rarely  spreads 
in  hospital  wards  to  non-infected  patients,  nor  does  it  seem  to  affect 
doctors  and  nurses,  as  is  the  case  of  practically  all  the  other  dis- 
eases that  are  spread  by  contact.  The  fact  that  the  disease  seems 
to  spread  radially  from  an  infected  center  so  that  the  most  recent 
cases  are  generally  found  to  be  the  farthest  away  from  the  center 
geographically.  It  would  seem  that  if  human  carriers  w^ere  respon- 
sible that  the  disease  ought  to  occur  in  almost  any  part  of  a  given 
area  after  a  very  short  space  of  time.  There  are  a  large  number 
of  such  curious  unexplainable  facts  which  certainly  lend  interest 
to  the  study  of  the  disease. 

The  extension  of  the  disease  may  be  singularly  irregular.  It 
may  spread  from  one  side  of  a  suburb  or  town  and  not  to  another, 
and  many  intervening  places  may  escape.  For  example,  there  was 
a  small  epidemic  in  1910,  in  Washington,  and  a  somewhat  smaller 
epidemic  the  same  year  in  Philadelphia.  Baltimore,  between  these, 
two,  showed  only  a  slight  increase  in  the  number  of  cases,  in  spite 
of  the  tremendous  intercourse  between  these  cities.  The  disease 
was  epidemic  in  New  York  in  1907  and  spread  north  into  New 
England,  but  did  not  spread  south  to  Philadelphia  or  to  any  of  the 
other  adjacent  cities.  The  more  recent  epidemics  of  1908,  1909, 
and  1910  in  Minnesota,  Nebraska,  Iowa,  and  Kansas  were  supposed 
to  follow  the  New  York  epidemic,  but  there  was  no  epidemic  in 
Chicago,  with  which  there  is  a  great  deal  more  connection  than 
the  places  mentioned. 

In  some  epidemics  the  rapid  spread  of  the  disease  over  wide 
areas  is  particularly  noticeable.  This  was  seen  in  the  epidemic  in 
Iowa  in  1910,  the  epidemic  so  well  described  by  Wickman  in  Sweden 
in  1905,  and  the  subsequent  epidemic  in  1911  reported  by  Kling. 


5§  EPIDEMIOLOGY 

The  question  of  animals  and  insects  has  been  pretty  thoroughly 
studied,  and  the  disease  does  not  bear  any  relation  to  the  paralytic 
diseases  in  animals  as  far  as  is  known  at  the  present  time.  The 
paralytic  diseases  of  animals  are  chiefly  of  the  polyneuritic  type, 
and  in  spite  of  a  very  considerable  number  of  studies,  no  one  has 
been  able  to  bring  them  into  direct  relation  to  poliomyelitis  in 
man.  One  after  another  the  insects  have  been  blamed,  studied, 
and  shown  not  to  be  the  active  carriers  of  the  disease.  This  is 
true  of  all  the  small  insects  with  the  exception  of  the  flea.  The  house- 
fly, the  bed-bug,  lice,  and  other  insects  certainly  can,  on  the  experi- 
mental evidence  at  hand,  be  ruled  out.  There  have  been  many 
efforts  made  to  establish  the  stable-fly,  Stomoxys  calcitrans,  but 
this  fly  has  also  been  pretty  w^ell  excluded.  It  has  been  shown  that 
flies  contaminated  with  the  virus  may  have  it  on  them  in  an  active 
state  as  long  as  forty-eight  hours  after  exposure.  Thus  it  may 
seem  that  the  fly  may  act  as  a  passive  carrier  of  the  disease.  In 
connection  with  the  flea  and  the  rat,  we  submit  the  following 
observations  of  Richardson: 

The  Rat  and  Poliomyelitis.— Richardson^  does  not  believe  that 
poliomyelitis  is  transferred  from  person  to  person  by  direct  or 
indirect  contact,  but  that  in  some  manner  insects  play  an  important 
role  in  the  epidemiology.  He  presents  his  ideas  in  two  categories: 
(1)  the  arguments  which  militate  against  transferring  the  disease 
from  person  to  person  by  direct  or  indirect  contact,  and  (2)  the  part 
played  by  rats  or  other  rodents  and  by  insects  on  the  rats  or  rodents 
or  by  both  in  combination.  The  chief  arguments  against  the  trans- 
fer by  direct  or  indirect  human  contact  which  he  gives  are  the  facts 
that  the  virus  most  closely  resembles  that  of  rabies,  which  is  essen- 
tially an  animal  disease.  The  virus  of  rabies  is  widely  disseminated 
through  the  body  and  is  present  in  the  saliva,  and  yet  the  disease 
is  not  transferred  from  individual  to  individual  except  through 
the  agency  of  a  punctured  wound.  The  seasonal  incidence  of 
poliomyelitis  and  the  maximum  prevalence  of  the  disease  in  country 
districts,  and  the  failure  to  spread  in  hospitals  and  in  institutions, 
he  also  points  out  as  against  the  direct  human  contact  theory.  The 
extreme  rarity  of  the  disease  in  doctors  and  nurses  and  the  entire 
absence  of  infection  of  laboratory  workers,  the  comparatively  rare 
occurrence  of  more  than  one  case  of  the  disease  in  one  family,  even 
under  the  markedly  congested  conditions  of  tenement  life,  and  that 

1  Boston  Med.  and  Surg.  Jour.,  September  21,  1916,  p.  397. 


POLIOMYELITIS  AND  CONrACf  59 

epidemics  often  cease  before  the  human  material  has  been  exhausted, 
and  when  the  opportunities  for  (Hrect  or  inchrect  contact  are  at  their 
maximum.  He  also  brings  out  curious  points  regarding  the  spread 
of  the  disease,  particularly  that  the  disease  has  been  noted  to  travel 
radially  from  the  centers  of  infection,  and  it  is  very  common  to  find 
the  later  cases  on  the  outskirts  of  the  infected  area,  whereas  if  a 
third  person  or  indirect  contact  were  responsible  for  the  spread  of  the 
disease  we  should  expect  to  have  an  irregular  distribution  and  to 
find  early  as  well  as  late  cases  on  the  periphery. 

Supporting  the  theory  that  the  disease  is  transferred  b}'  rodents, 
by  insects,  or  both,  he  gives  a  summary  index  of  the  disease  and  the 
exclusion  of  other  animals  or  insect  carriers.  The  relation  of  the 
rat  to  the  disease  was  first  called  to  his  attention  in  1910  through 
an  observation  made  by  Dr.  Charles  E.  Simpson,  Director  of 
Health.  He  calls  attention  to  the  migratory  habits  of  rats,  par- 
ticularly the  studies  of  Creel^  whose  work  was  reviewed  in  Pro- 
gressive Medicine  last  year.  He  also  adds  a  note  to  the  effect  that 
Rosenau  told  him  that  he  had  been  able  to  produce  a  paralytic 
disease  in  rats  by  inoculation  with  the  virus  of  poliomyelitis,  but 
that  the  experimental  data  are  not  sufficiently  advanced  to  draw 
any  definite  conclusions.  He  assumes  the  transfer  of  the  disease 
from  rat  to  man  through  the  agency  of  the  flea. 

It  seems  strange  that  the  necessary  experimental  work  to  prove 
or  disprove  this  theory  of  the  rat  and  flea  acting  as  carriers  has  not 
been  already  done.  There  is  no  doubt  that  it  will  soon  be  added  to 
our  store  of  information  on  the  subject. 

Poliomyelitis  and  Contact. — The  statistics  on  this  question  are  of 
but  little  value  and  the  question  needs  thorough  restudying  in  the 
light  of  our  present-day  knowledge.  The  disease  seems  to  be  less 
contagious  than  scarlet  fever  or  diphtheria,  even  counting  in 
doubtful  cases,  but  whether  this  would  prove  true  of  an  accurate 
diagnosis  as  made  in  all  non-paralytic  cases,  we  have  no  means 
of  telling  at  the  present  time.  There  will  probably  be  found 
to  be  variations  in  different  epidemics  due  to  the  amount  of 
immunity  encountered  in  the  population  and  to  the  intensity 
of  the  virus.  In  1910,  in  Pennsylvania,  there  were  289  children 
who  slept  in  the  same  room  with  paralytic  cases  and  only  24 
contracted  the  disease.  In  Massachusetts,  in  1908-10,  out  of  357 
cases  there  was  only  1  case  in  a  family,  2  cases  in  twenty-seven, 

1  Prog.  Med.,  March,  1916,  p.  201. 


60 


EPIDEMIOLOGY 


and  3  cases  in  three.  Out  of  350  cases  studied  with  reference  to 
contact  -R-ith  acute  cases,  possible  abortive  cases,  chronic  cases, 
or  certain  indirect  contact  with  an  acute  case  by  a  tliird  person, 
only  82  were  foimd  to  have  had  such  contact.  Institutions  for 
children  seem  to  be  singularly  free  from  the  disease,  probably  on 


SAT  NEXT  TO  C.C. 

AT  W.OVIE  SHOW 

AUGUST  10TH 

ONSET  AJG.   ISTH 


ATTESOEO  SAME 


AUGUST  19TH 


OF 


AUGUST  18TH 


SAT 

CO.  Iafter 

QUARANTINE 
AUGUST  ^TH 
AUGUST  20TH 


LIVED  OTHER  SIDE 

OF  HO_USE  WITH   C.R, 

ONSET  AUG.  28TH 


Fig.  15. — Development  of  a  contact  group  of  poliomyelitis  cases  in  Jefferson 
Countj-  dirring  August,  1916.  (Courtesj-  of  Dr.  Alathias  Nicoll,  Jr.,  New  York 
State  Board  of  Health.) 


account  of  theu-  not  having  had  as  much  contact  ^ith  the  outside 
■world.  In  ^Massachusetts  in  44  mstitutions,  -^dth  3600  children 
under  fifteen  years  of  age,  there  was  only  1  case  from  1908  to  1910, 
an  incidence  per  1000  of  0.277  per  cent.,  whereas  the  incidence 
per  1000  for  the  other  children  of  the  State  under  fifteen  years  of 
age  was  0.625. 

The  analysis  of  700  cases  of  the  New  York  epidemic  of  1916^ 
showed  the  following: 

Per  cent,  of 
Families.  Cases.  total  families. 

1  case  in  a  family 6521  6521  96.63 

2  cases  in  a  family 205  410                   3.04 

3  cases  in  a  family 20  60                   0.3 

4  cases  in  a  family 1  4                   0.014 

5  cases  in  a  family 1  5                   0.014 

6748  7000  99.998 

The  above  figures  do  not  indicate  the  number  of  children  in  each 
family;  studies  are  being  made  along  this  line  and  further  informa- 
tion will  soon  be  added  on  this  interesting  subject. 

"  Weekly  Bulletin  of  the  Department  of  Health  of  the  City  of  New  York,  Sep- 
tember 16,  1916,  p.  297. 


RAILROADS  AND   WATER  COURSES  61 

These  figures  could  be  multiplied  from  experience  with  other 
epidemics,  but  all  show  about  the  same  thing. 

Food. — As  far  as  we  know  there  is  no  direct  evidence  to  show  that 
the  disease  is  transmitted  in  foods  of  any  kind,  and  yet  one  must 
keep  an  open  mind  on  the  subject,  as  it  may  be  possible  that  it  is 
transmitted  on  gi-een  vegetables,  fruits,  and  salads.  It  is  conceivable 
that  such  uncooked  food  may  be  contaminated  by  dust  or  human 
excretions  and  so  cause  the  disease,  but  we  have  seen  that  the 
disease  does  not  bear  any  relation  to  the  disposal  of  sewage,  so  it 
seems  highly  improbable  that  it  could  be  carried  on  foods.  It  has 
been  thought  that  it  might  be  carried  in  milk,  and  in  one  of  the 
small  epidemics  reported  by  Wickman  it  seemed  possible  that  the 
milk  supply  may  have  had  something  to  do  with  the  spread  of  the 
disease ;  but  careful  epidemiological  studies  in  various  cities  have  not 
been  able  to  show  any  connection  whatever  between  the  milk 
supply  and  the  disease.  The  greatest  argument  against  its  trans- 
mission in  milk  is  the  fact  that  it  may  occur  in  exclusively  breast- 
fed infants.  In  the  Massachusetts  report  of  1910  there  were  six 
babies  under  six  months  of  age  who  had  never  had  anything  but 
breast  milk.  In  the  New  York  epidemic  of  1907,  out  of  283  exclu- 
sively breast-fed  infants  under  two  years  of  age,  there  were  121 
cases,  and  in  1916,  in  115  cases  under  one  year  of  age,  41  were 
breast  fed  exclusively. 

Sewage. — The  disease  bears  no  relation  whatever  to  the  presence 
or  absence  of  sewerage  system  nor  to  the  method  of  disposal  of 
sewage,  which  should  seem  to  indicate  pretty  conclusively  that  the 
virus  is  not  transmitted  from  the  discharges  from  the  body.  It 
will  be  remembered  that  the  virus  has  been  demonstrated  in  the 
washings  from  the  rectum,  but  the  disease  certainly  does  not  bear 
any  resemblance  to  any  of  the  diseases  that  are  transmitted  through 
the  causative  agent  being  discharged  from  the  bowel. 

Railroads  and  Water  Courses. — While  the  disease  spreads  definitely 
along  the  lines  of  human  travel — that  is,  points  connecte  d  by  rail- 
roads or  waterways — the  occurrence  of  the  disease  does  not  seem 
to  bear  any  relation  to  the  actual  railroad  itself  nor  to  the  waterways. 
In  the  Massachusetts  epidemic,  30.56  per  cent,  of  the  cases  were 
found  to  be  one-eighth  of  a  mile  from  the  railroad,  whereas  69.2 
per  cent,  of  the  cases  were  found  one-quarter  of  a  mile  awaj""  from  a 
railroad.  There  are  some  instances  in  which  the  disease  seems  to 
bear  some  relation  to  watercourses,  but  on  analysis  this  would  not 
seem  to  be  so,  although  in  the  New  York  epidemic  of  1916  there  was 


62  EPIDEMIOLOGY 

a  distinct  tendency  for  the  disease  to  propagate  along  the  water 
fronts. 

Relation  to  Dust. — Neustaedter  and  Thro^  claim  to  have  found  the 
virus  in  the  sweepings  from  a  house  in  which  three  different  cases 
had  occurred.  As  far  as  we  know  these  observations  have  not  been 
confirmed.  There  have  been  numerous  studies  made,  and  at  one 
time  it  was  thought  that  the  disease  was  more  common  in  dry- 
seasons  and  that  dust  might  play  a  part  in  the  transmission  of  it; 
but  the  fact  that  there  have  been  at  least  two  epidemics  in  very 
wet  seasons,  one  in  Cincinnati  in  1911  and  one  in  Buffalo  in  1912, 
seem  to  throw  a  very  considerable  doubt  on  dust  as  a  possible 
source  of  infection. 

Race. — ^There  has  been  a  general  impression  that  the  negro  is  more 
or  less  exempt  from  the  disease,  but  comparison  of  the  following 
figures  of  cases  at  the  Children's  Hospital  School,  Baltimore,  shows 
that  they  may  not  only  be  attacked  with  considerable  frequency 
in  certain  epidemics,  but  also  that  the  disease  may  be  just  as  fatal 
in  them  as  in  the  white  children: 

White  Admissions. 

Males  (ages  varied  from  four  months  to  ten  years) 43 

Females  (ages  varied  from  four  months  to  ten  years) 34 

White  Died. 

Males  (ages  varied  from  10  months  to  seven  years) 9 

Females  (ages  varied  from  six  months  to  two  and  a  half  years)       .      .       4 

Black  Admissions. 

Males  (ages  varied  from  eight  weeks  t;0  five  years)     ......      18 

Females  (ages  varied  from  six  months  to  four  years 16 

Black  Died. 

Males  (ages  varied  from  fifteen  months  to  six  years) 3 

Females  (ages  varied  from  four  months  to  five  years) 3 

What  influence,  if  any,  is  played  by  nativity  may  be  studied 
from  the  following  table,  which  shows  the  nativity  of  the  parents  of 
848  fatal  cases  in  the  New  York  epidemic  of  1916: 

Both  parents  born  in  United  States 253 

Both  parents  born  in  Italy 177 

Both  parents  born  in  Russia 115 

Both  parents  born  in  Ireland 40 

Both  parents  born  in  Austria-Hungary 39 

Both  parents  born  in  Germany 23 

Both  parents  born  in  other  foreign  countries 120 

Total  foreign 514 

Mixed  native  and  foreign 81  • 

Total 848 

1  New  York  Med.  Jour.,  September  23,  1911,  p.  613;  October  9,  1911,  p.  813. 


AGE 


63 


Sex. — In  a  general  way  the  proportion  of  males  and  females  is 
nearly  the  same,  but  almost  all  epidemics  show  a  slightly  greater 
proportion  of  males  than  females,  sometimes  as  high  as  GO  to  40. 
Thus  in  ^Massachusetts  in  19  07  and  in  1910  the  ])roportion  was  about 
56  per  cent,  of  males  to  44  per  cent,  of  females.  In  some  epidemics 
the  proportion  of  males  and  females  in  young  children  is  nearly  the 
same.  In  later  life,  howe\'er,  the  proportion  of  males  seems  to  grow 
increasingly  greater.  The  disease  is  more  liable  to  be  severe  in  boys 
and  the  mortalit^'  rate  somewhat  higher. 


Fig.  16. — Comparative  age  distribution  of  deaths  from  poliomyelitis  during  the 
epidemic  of  1916,  in  New  York  City,  upstate  cities,  and  rural  New  York.  (Courtesy 
of  Dr.  Mathias  Nicoll,  Jr.,  New  York  State  Board  of  Health.) 

Age. — There  have  been  some  variations  in  the  various  epidemics 
as  regards  the  age  of  the  individuals  chiefly  affected,  but  in  a  general 
way  it  may  be  said  that  the  largest  proportion  of  cases  occurs 
between  the  first  and  fifth  year.  Whether  or  not  the  disease  occurs 
in  vtero  has  not  been  definitely  settled,  but  it  seems  highly  probable 
that  this  is  possible  and  there  have  been  some  reports  made  bearing 
upon  this  topic.  INIorton,^  Batten  and  others  have  reported  cases 
which  they  believe  to  be  examples  of  intra-uterine  infection.  This 
whole  subject  is  one  for  futiu'e  investigation  and  a  careful  study  of 
all  children  born  during  an  epidemic,  particularly  of  the  cases  born 


Philadelpliia  Med.  News,  July  12,  1S90. 


64 


EPIDEMIOLOGY 


of  mothers  who  are  affected  with  an  acute  attack  during  the  epidemic 
might  serve  to  clear  up  this  important  point.  While  the  disease  is 
not  particularly  common  in  the  first  year  of  life  it  occurs  T^^th 
considerable  frequency.  Duchenne  has  reported  a  case  twelve  days 
after  birth  and  BramwelP  one  of  three  weeks  of  age,  and  Sinkler 
two  cases  under  one  month  of  age. 


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Fig.  17. — Chart  showing  graphically  age  incidence  of  1076  cases  of  poliomyelitis 
recorded  in  1910.     (Department  of  Health  of  Pennsj-lvania.) 

The  adults  are  affected  generally  to  the  extent  of  about  10  per 
cent,  of  the  various  epidemics,  but  in  this  there  are  great  variations, 
at  times  the  percentage  being  higher  and  sometimes  very  much 


1  Studies  in  Clinical  Medicine,  No.  1,  i,  11. 


AGE 


65 


lower.  Where  the  epidemic  affects  a  very  large  number  of  the 
population  the  proportion  of  adult  cases  seems  to  be  high  anrl  a 
remarkable  instance  is  reported  by  Miiller^  of  an  epidemic  on  the 
island  of  Nauru,  where,  in  a  population  slightly  over  25,000,  some 


0 

RATE 


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Fig.  18. — Comparative  incidence  rates  of  poliomyelitis,  by  age  periods,  in  different 
sections  of  New  York  State  during  the  epidemic  of  1916.  (Courtesy  of  Dr.  Mathias 
Nicoll,  Jr.,  New  York  State  Board  of  Health.) 

700  cases  occurred  within  a  few  weeks,  the  majority  of  which  were 
in  adults. 

The  following  table  gives  some  of  the  figures  from  some  of  the 
reported  epidemics : 


1  Arch,  f.  Schiffs  u.  Trop.  Hyg.,  1910,  xiv,  No.  17. 


66  EPIDEMIOLOGY 

By  Age  Periods.    Massachusetts  Epidemic  of  1910. 

Per  cent. 
Cases.  Approximate. 

From  birth  to  twelve  months,  inclusive         ....  51  8.5 
From  thirteen  months  to  twenty-three  months,  inclu- 
sive        65 

Two  years  old 61 

Three  years  old 98 

Four  years  old 69 

Five  years  old 51  65 . 5 

395 

Six  to  ten  years,  inclusive 93  80.8 

488 
Eleven  to  twenty  years,  inclusive 69  92.1 

557 

Twenty-one  to  thirty  years,  inclusive 28 

Thirty-one  to  eighty  years,  inclusive 15 

600 

Occurrence  by  Age  Periods  (1908-10). 

Age,  years.  Cases.  Per  cent. 

Birth  to  twelve  months  inclusive 55  6.13 

One  year  old 119  13.26 

Two  years  old 155  17.35 

Three  years  old 125  13.93 

Four  j^ears  old   . 92  10 .  25 

Five  years  old 54  6 .  02 


600 
Six  to  ten  years,  inclusive 145 

745 
Eleven  to  twentj^  years,  inclusive       .      .      .      .      .      .83 


828  92.35 

Twenty-one  to  thirty  years,  inclusive 39  4.34 

Thirty-one  to  seventy-two  years,  inclusive  ....     17  1.89 

Not  stated 13 

897 

Age  Incidence  in  Five-year  Periods,  Expressed  in 
Percentages.     (Erost.)^ 

New  York 

Commission          Lovett,  Mass.  Hill,  Minn. 

(729  cases;               (615  cases;  (325  cases: 

per  cent,  of             per  cent,  of  per  cent,  of 

Age.                                                          total).                       total).  total). 

Under  one  year 8.5                         7.2  6.5 

One  to  five  years 82.0                       64.5  48.6 

Eleven  to  fifteen  years      ....1.9                         5.0  7.7 

Sixteen  to  twenty  years    ....0.68                       2.4  6.5 

Over  twenty  years 0.4                         5.0  7.0 

>  Jour.  Am.  Med,  Assn.,  June  10,  1910. 


RELATION  OF  NOSE  AND   THROAT  TO   POLIOMYELITIS     07 

Social  and  Hygienic  Conditions. — Curiously  enough,  in  a  general 
way  the  influence  of  poverty  and  unsanitary  conditions  does  not 
seem  to  be  as  important  in  poliomyelitis  as  in  other  diseases.  In  the 
New  York  epidemic  of  1916  Emerson  cites  the  fact  that  Barren 
Island,  in  Jamaica  Bay,  on  which  all  garbage  and  dead  animals  frf>m 
New  York  City  are  dumped  and  which  has  no  public  water  supply, 
no  sewerage  system,  no  cellars  and  no  garbage  collection  and  on 
which  1700  people,  of  which  350  are  children,  live — the  sanitary 
conditions  may  well  be  imagined — there  was  not  a  single  case  of 
poliomyelitis.  The  same  absence  of  the  disease  has  been  noted  on 
other  islands  by  other  observers,  showing  that  the  virus  must  be 
introduced  into  a  community  before  the  disease  starts.  Most 
authors  state  that  rich  and  poor  are  affected  alike,  and  taking  into 
consideration  the  relative  numbers  of  both,  this  is  apparently  true. 
Numerically,  the  greatest  number  of  cases  occur  in  poor  people, 
but  when  one  takes  into  account  that  very  much  larger  proportion 
of  persons  with  insufficient  income,  the  figures  are  easily  explained. 
The  character  of  houses  does  not  seem  to  make  any  particular 
difference,  the  disease  occurring  with  about  the  same  frequency  in 
tenements  as  in  detached  houses.  This  point  was  carefully  studied 
in  the  epidemics  occurring  in  Massachusetts. 

Poliomyelitis  in  Lower  Floors. — A  point  of  extraordinary  interest 
is  brought  out  in  the  New  York  epidemic  of  1916,  in  which  it  was 
found  that  most  of  the  cases  of  the  disease  occurred  on  the  first 
and  second  floors  of  the  taller  houses  and  a  very  much  lesser  pro- 
portion of  cases  on  the  floors  above.  The  explanation  of  the  greater 
number  of  cases  on  the  lower  floors  may  be  due  to  the  fact  that 
they  have  less  light,  less  air,  and  are  more  exposed  to  rodents  than 
the  upper  floors.  Scarlet  fever  and  diphtheria  do  not  show  this 
tendency  to  show  a  larger  number  of  cases  in  the  lower  stories. 

This  point  may  be  of  importance  in  solving  the  problem  of 
transmission,  inasmuch  as  it  seems  to  be  a  point  in  the  favor  of  the 
possibility  of  the  disease  being  transmitted  by  rat  fleas. 

The  Relation  of  the  Nose  and  Throat  to  Poliomyelitis.- — In  the  New 
York  epidemic  of  1916  a  study  was  made  to  determine  if  there  was 
any  relation  to  diseases  of  the  nose  and  throat  and  poliomyelitis, 
and  whether  the  disease  was  more  common  with  adenoids  and 
tonsils  than  in  those  in  whom  they  had  been  removed.  It  was 
found  that  a  large  number  of  children  with  poliomyelitis  had 
pathological  conditions  of  the  nose  and  throat,  either  disease  and 
hypertrophy  of  the  tonsils  and  adenoids  or  both.    This,  of  course, 


68  EPIDEMIOLOGY 

would  be  expected,  as  disease  of  the  tonsils  and  adenoids  is  extremely 
common  at  the  present  day  in  early  life.  It  was  also  noted  that  a 
large  number  of  children  with  poliomyelitis  showed  marked  hyper- 
emia of  the  nasopharynx  and  throat,  that  is,  of  the  tonsils,  anterior 
pillars,  and  soft  palate.  This  condition  often  resembled  that  seen 
in  scarlet  fever,  or  due  to  infection  with  a  streptococcus.  It  was 
also  observed  that  only  a  small  percentage  of  cases  previously 
operated  on  for  tonsils  and  adenoids  were  found  afterward  with 
the  disease,  and  in  that  group  of  cases  the  percentage  of  recoveries 
was  very  much  higher  than  in  unoperated  cases.  The  number  is 
too  small  to  draw  any  very  definite  conclusions,  but  at  the  same 
time  it  is  very  suggestive. 

A  series  of  2000  cases  was  studied.  Of  these,  45  had  been  oper- 
ated upon;  19  out  of  39  of  these  recovered  completely,  or  46  per 
cent.;  1955  cases  were  not  operated  upon.  There  were  complete 
recoveries  in  but  15  per  cent.  While  these  observations  are  strik- 
ing, one  should  be  slow  in  jumping  at  any  conclusion,  and  they 
should  be  confirmed  by  other  observers  in  other  localities  before 
being  made  a  basis  for  practical  application. 

Another  study  was  undertaken  on  1404  children  whose  tonsils 
and  adenoids  had  been  removed.  Not  one  of  these  developed  the 
disease,  although  in  18  instances  cases  developed  in  the  family,  and 
in  93  instances  in  the  same  house. 

Poliomyelitis  and  Decayed  Teeth.^ — Fischer^  suggests  the  possi- 
bility of  the  infection  entering  through  carious  teeth.  Whether  or 
not  this  is  the  case,  the  mere  suggestion  is  a  very  strong  point  in 
urging  the  all-important  dental  hygiene,  a  much  neglected  point, 
particularly  in  children. 

Type  of  Child  Most  Often  Affected. — Draper-  has  made  some 
interesting  observations  which  we  quote  verbatim: 

"The  type  of  child  which  seems  to  be  most  susceptible  to  the 
disease  is  the  large,  well-grown,  plump  individual  who  has  certain 
definite  characteristics  of  face  and  jaws,  is  broad-browed  and  broad 
and  round  of  face.  The  teeth  are  particularly  interesting.  It  was 
noted  that  in  50  to  60  per  cent,  of  all  the  cases  in  the  hospital  at 
Locust  Valley  the  central  incisor  teeth  of  the  upper  jaw  were  sepa- 
rated by  a  cleft  of  varying  width.  The  wide-spaced  dentition  has 
been  a  striking  feature  and  frequently  involves  all  the  single  teeth 
of  both  jaws,  so  that  each  tooth  stands  entirely  free. 

1  Weekly  Bulletin  of  the  Department  of  Health  of  New  York,  May  12.  1917,  p.  146. 

2  Acute  Poliomyelitis,  p.  8. 


THE  NEW   YORK  EPIDEMIC  09 

"Among  the  adolescents  and  young  adults  who  acquired  polio- 
myelitis and  in  whom  the  disease  always  seemed  to  be  most  severe 
and,  indeed,  usually  fatal,  the  type  differed  from  that  just  described. 
Instead  of  the  \'ery  large,  well-nourished  individuals  with  widely 
spaced  teeth,  there  appeared  a  more  delicately  made  type.  Of  the 
6  or  8  fatal  cases  in  young  adults  seen,  the  similarity  of  appearance 
of  the  individuals  was  so  striking  that  all  might  ha^'e  been  of  one 
family.  x\ll  were  brunettes,  with  very  delicate  dark  skins  and  high 
coloring  of  cheeks  and  lips.  Often,  small,  deeply  pigmented  moles 
were  present  on  face  or  neck.  In  all  cases  there  was  present  a  certain 
maxillary  prognathism  and  instead  of  dental  separations  a  tendency 
to  crowding  of  the  teeth." 

Immunity. — Flexner  and  Lewis  have  demonstrated  that  mon- 
keys that  have  had  the  disease  and  recovered  are  immune  to  further 
inoculations  and  individuals  who  have  had  an  attack  are  appar- 
ently immune,  but  there  are  some  exceptions  to  this.  (See  Relapses 
or  Recurrences.)  In  the  New  York  epidemic  of  1916  there  were 
two  instances  of  the  disease  in  children  who  had  had  previous 
attacks.  This  subject  will  need  further  study  to  determine  how 
long  the  immunity  lasts.  It  would  seem  that  it  would  be  possible 
to  clear  up  one  of  the  moot  points  as  to  whether  a  large  proportion 
of  the  population  had  had  the  disease  by  some  time  making  proper 
tests  of  the  blood  on  a  large  number  of  individuals  selected  at  ran- 
dom. This,  of  course,  would  be  an  exceedingly  expensive  and 
tedious  undertaking,  but,  at  the  same  time,  one  that  would  be 
perfectly  feasible. 

The  New  York  Epidemic. — In  the  year  1916  the  State  of  New  York 
experienced  the  most  extensive  epidemic  of  poliomyelitis  on  record. 
We  are  indebted  to  Dr.  Mathias  Xicoll,  Jr.,  of  the  New  York 
State  Department  of  Health,  for  this  account  of  it :  From  June  to 
December  there  were  13,000  cases  and  3300  deaths.  Of  these, 
8991,  or  more  than  tw^o-thirds,  occurred  in  New  York  City,  4186 
representing  the  cases  in  the  other  part  of  the  State.  The  epidemic 
began  early  in  June  in  the  Borough  of  Brooklyn.  First  the  spread 
was  slow,  but  later  increased  in  intensity  and  later  invaded  practi- 
cally the  entire  State.  The  disease  spread  along  the  routes  of 
travel,  particularly  the  suburban  lines  out  of  New  York  City,  east 
into  Nassau  and  Suffolk  counties,  and  northward  to  the  outlying 
communities  in  Westchester.  The  counties  bordering  on  the 
Hudson  River  w^ere  then  invaded  and  the  disease  spread  north  and 
northwest  along  the  railroad  lines  out  of  the  State, 


70 


EPIDEMIOLOGY 


The  fatality  rate  was  about  25  per  cent.,  which  is  higher  than  the 
rate  observed  in  any  of  the  previous  large  epidemics.  The  table 
of  the  epidemic  shows  an  apparent  increase  in  the  fatality  rate 
toward  the  end,  but  this  was  probably  due  to  the  fact  that  the 
number  of  cases  were  rapidly  diminishing,  while  the  previously 
reported  cases  were  dying  off;  this  causes  the  apparent  increase  in 
the  rate. 


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JUNE  JULY        AUGUST    SEPTEMBER     OCTOBER     NOVEMBER   DEC. 

Fig.  19. — Reported  cases  of  poliomyelitis,  week  by  week,  during  the  epidemic  of 
1916,  in  New  York  City  (dates  of  report)  and  upstate  (dates  of  onset).  (Courtesy 
of  Dr.  Mathias  Nicoll,  Jr.,  New  York  State  Board  of  Health.) 


In  the  rural  districts  a  much  higher  proportion  of  the  population 
was  affected  than  either  in  New  York  City  or  the  up-State  cities. 
On  an  average,  2.4  per  cent,  of  the  persons  of  the  rural  sections  were 
attacked  and  only  1.6  in  New  York  City,  and  0.6  per  thousand  in 
the  up-State  cities,  as  a  whole.  The  deaths,  however,  were  less  in 
the  rural  sections,  19.8  per  cent.,  the  up-State  cities  following  with 
22.6  deaths  per  100  cases,  and  in  New  York  City,  27.2  per  cent. 
The  number  of  deaths  among  males  was  50  per  cent,  higher  than 
among  females.  Practically  the  same  proportion,  60  and  40  per 
cent,  were  observed  in  New  York  City  and  up-State,  at  the  different 
ages  and  from  month  to  month. 

In  the  first  7500  cases  in  New  York  City,  almost  80  per  cent,  were 
among  children  under  five  years  of  age;  over  95  per  cent,  under 
ten,  and  over  98  per  cent,  under  sixteen,  while  in  the  up-State  less 
than  two-thirds  of  the  cases  were  under  five  years,  86  per  cent. 


THE  NEW   YORK  EPIDEMIC 


71 


under  ten,  and  over  7  per  cent,  beyond  the  age  of  fifteen.  In  rural 
New  York  only  55  per  cent,  of  the  ca.ses  occurred  amonfj  children 
under  five  years  of  age,  half  as  many  between  the  ages  of  five  and 
ten,  and  10  per  cent,  of  all  cases  were  among  persons  older  than 
fifteen.    The  higher  fatality  among  adults  shows  a  decided  contrast 


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Fig.  20. — Relative  severity  of  poliomyelitis  epidemic  of  1916  in  certain  areas, 
judged  by  the  comparative  incidence  and  death-rates  recorded.  (Courtesy  of  Dr. 
Mathias  NicoU,  Jr.,  New  York  State  Board  of  Health.) 


in  the  difTerent  sections.  In  Xew  York  City  nearly  4  out  of  e\-ery 
5  deaths  were  under  five  years  of  age,  and  97  per  cent,  of  all  deaths 
occurred  among  persons  under  fifteen  years  of  age.  In  the  rural 
districts  45.5  per  cent,  were  under  five  years,  and  80.9  per  cent, 
under  fifteen,  with  fully  19.1  per  cent.,  or  1  out  of  every  5  deaths 


72  EPIDEMIOLOGY 

occurring  in  adults,  that  is,  persons  beyond  the  age  of  fifteen.  It 
has  been  suggested  that  the  explanation  of  the  difference  is  that 
the  urban  population  has  acquired  a  certain  degree  of  immunity, 
while  the  rural  population,  being  more  scattered  and  less  in  contact, 
has  not. 

A  study  made  to  determine  the  length  of  time  persons  with  the 
disease  were  a  source  of  active  infection  show  that  the  period  is  at 
least  eight  days  after  the  onset  of  the  disease,  and  there  was  very 
little  evidence  of  the  disease  being  contracted  from  a  person  who 
had  been  ill  longer  than  two  weeks,  which  suggests  the  limit  of  the 
necessary  period  of  isolation  be  required  for  suspected  cases  in 
future  epidemics. 

One  of  the  lessons  learned  from  the  epidemic  in  New  York  City 
was  the  value  of  publicity  and  education.  The  educational  cam- 
paign in  New  York  was  thoroughly  done  through  the  newspapers, 
by  distribution  of  literature,  and  so  on,  and  the  result  was  that  an 
unusual  degree  of  care  was  taken  of  all  children  as  regards  clean- 
liness, food,  and  all  other  precautions.  The  result  was  that  there 
has  been  a  saving  of  infant  life  in  New  York  City  sufficient  to  off- 
set the  number  of  deaths  from  infantile  paralysis.  During  the  first 
thirty-five  weeks  of  1916  out  of  every  1000  infants  born  95  died, 
while  during  the  first  thirty-five  weeks  of  1915  out  of  every  1000 
infants  born,  105  died.  The  infant  death-rate  is  a  fair  estimate  of 
the  sanitary  conditions  prevailing  in  a  community,  and  this  lowering 
in  New  York  is  attributed  to  the  efi'ect  of  education  which  resulted 
from  the  poliomyelitis  epidemic. 


CHAPTER   VI. 
THE  SYNOX^^MS  AND  CLASSIFICATION. 

SYNONYMS. 

The  best  term  for  cases  of  this  disease  is  poliomyelitis.  So  many 
different  terms  have  been  used  in  the  past  and  even  at  present,  for 
example,  in  1909,  the  Census  Bureau  had  twenty-four  terms  for  the 
disease,  that  it  would  seem  to  be  a  wise  thing  to  adopt  a  uniform 
terminology.  In  Europe,  where  there  is  a  tendency  to  couple 
physician's  names  to  diseases,  it  is  often  called  the  Heine-Medin 
disease. 

The  term  poliomyelitis  is  derived  from  the  Greek  words  polios, 
meaning  gray,  and  myelon,  meaning  marrow. 

The  following  list  shows  the  terms  that  have  been  or  are 
now  used: 

Dental  paralysis  (Underwood). 

Infantile  spinal  paralysis  (Heine). 

Paralysis  during  dentition  (Gule). 

Teething  paralysis  (Marshall  Hall). 

Morning  paralysis  (\Yest). 

Essential  paralysis  of  children  (Barthez  and  Rilliet). 

Regressive  paralysis  (Barlow). 

Myelitis  of  the  anterior  horns  (Seguin). 

Tephromyelitis  (Charcot)  from  the  Greek  tephros,  meaning  ash- 
gray. 

Spodomyelitis  or  spodiomyelitis  (^'ulpian)  also  from  the  Greek 
spodios,  meaning  ash-gray,  according  to  Erb. 

Acute  fatty  atrophic  paralysis  (Duchenne)  afterward  shortened 
to  atrophic  paralysis. 

]\Iyogenic  paralysis  (Bouchut). 

Idiopathic  paralysis. 

Infantile  paralysis. 

Essential  paralysis. 

Acute  spinal  paralysis. 

Acute  infantile  paralysis. 

Poliomyelitis  anterior  acuta. 

Anterior  poliomyelitis. 


74  THE  SYNONYMS  AND  CLASSIFICATION 

THE   CLASSIFICATION. 

The  question  of  classification  is  a  somewhat  difficult  one,  inas- 
much as  the  clinical  manifestations  of  the  disease  do  not  always 
correspond  to  the  pathological  findings.  The  lesions  are  apt  to  be 
widespread  and  scattered  throughout  the  whole  nervous  system, 
so  that  while  certain  definite  types  of  the  disease  may  be  described, 
there  will  always  be  cases  which  come  partly  under  one  group  and 
partly  under  another.  This  will  be  made  more  clear  by  considering 
the  classifications  that  have  been  suggested.  There  is  no  real  need 
for  exact  classification  except  that  it  facilitates  the  description  of 
the  disease  and  makes  the  task  of  learning  about  it  simpler. 

The  first  classification  of  any  importance  is  that  of  Wickman. 
He  divides  the  cases  into  the  following  forms: 

1.  The  spinal  poliomyelitic  form. 

2.  The  form  resembling  Landry's  paralysis. 

3.  The  bulbar  or  pontine  form. 

4.  The  encephalitic. 

5.  The  ataxic. 

6.  The  polyneuritic  (resembling  neuritis). 

7.  The  meningitic. 

8.  The  abortive. 

This  classification  is  most  useful  from  a  clinical  standpoint  in 
that  it  gives  the  different  forms  as  they  are  met  with  in  practice 
and  for  purposes  of  description  has  much  to  recommend  it. 

Zappert  suggested  three  groups : 

1.  Cases  in  which  spinal  paralysis  preponderates  and  in  which  the 
respiratory  tracts  were  eventually  involved  (Landry's  paralysis). 

2.  Cases  with  marked  cerebral  symptoms  referable  to  involve- 
ment of  the  cranial  nerves  or  the  cerebral  cortex. 

3.  Cases  without  any  special  involvement  of  the  central  nervous 
system,  but  with  more  or  less  marked  general  febrile,  meningeal  or 
gastro-intestinal  symptoms. 

Krause  suggested: 

1.  Spinal  form  (poliomyelitis  acuta). 

2.  A  bulbar  form. 

3.  Cerebral  form:  (a)  meningitic;  (fe)  encephalitic;  (c)  ataxic. 

4.  Abortive  form. 

5.  Recurrent  or  relapsing  form. 

Holt  and  Howland  suggested  dividing  the  cases  into  cerebral, 
spinal,  bulbospinal,  and  non-paralytic  or  the   so-called    abortive 


CLASSIFICATION  75 

form.  Miiller  suggested  nearly  the  same,  dividing  the  cases  into 
spinal,  bulbar,  cerebral  and  abortive.  All  the  above  are  based  on 
variations  in  the  symptomatology.  Peabody,  Draper  and  Dochez 
have  suggested  a  classification  which  is  the  best  for  gi\ing  a  real 
understanfling  of  the  disease.  They  suggest  three  groups:  first, 
the  non-paralytic  or  so-called  abortive  cases  in  which  the  infection 
does  not  invade  the  central  nervous  system,  at  any  rate,  not  suffi- 
ciently to  produce  any  paralysis.  The  cases  with  paralysis  form  the 
other  two  groups:  first,  those  in  which  the  upper  motor  neuron  is 
primarily  aflected,  and  second,  the  larger  group  of  cases  in  which 
the  lower  motor  neuron  is  involved.  In  the  first  paralytic  group 
would  come  the  true  encephalitic  or  cerebral  cases,  originally 
described  by  Striimpell,  in  which  the  lesion  is  probably  either  in 
the  cortex  or  in  the  pyramidal  tracts,  either  high  up  or  in  the  cord. 
This  form  is  characterized  by  a  spastic  paralysis.  In  the  second 
group  the  ordinary  paralytic  form  met  with  in  practice  has  the 
lesion  in  the  lower  motor  neuron,  either  in  the  pons  or  medulla  or 
in  the  cord,  especially  in  the  anterior  horn  cells.  This  form  shows 
paralysis  of  the  muscles  supplied  by  the  cranial  nerves  or  flaccid 
paralysis  of  the  muscles  of  the  extremities  and  trunk.  Harbitz  and 
Scheel  and  others  have  described  cases  in  which  in  the  same  patient 
there  was  the  occurrence  of  both  spastic  and  flaccid  paralysis,  with 
lesions  both  in  the  upper  and  lower  motor  neuron.  Thus  it  is 
seen  that  any  classification  that  has  been  suggested  up  to  date 
occasionally  fails  to  fulfil  the  requirements. 

The  New  York  Health  Department  suggest  the  following  classi- 
fication: 

1.  Non-paralytic  or  abortive  cases. 

2.  Ataxic  cases  or  those  with  nystagmus  in  which  there  are 
anatomical  changes  in  Clarke's  column,  the  cerebellum  or  the  inter- 
vertebral ganglia.    These  cases  are  very  rare. 

3.  Cortical,  in  which  the  lesion  is  in  the  upper  motor  neuron. 
Also  rare. 

4.  Ordinary  spinal  or  subcortical,  in  which  the  lesion  is  in  the 
lower  motor  neuron. 

For  purposes  of  description  we  have  adopted  the  above  and 
subdivided  the  last,  or  ordinary  spinal  form,  into  the  meningitic, 
bulbar,  bulbospinal,  spinal,  polyneuritic  and  the  ascending  form. 
The  cases  described  as  meningitic  may  sometimes  be  incorrectly 
placed  in  this  classification,  but  that  is  not  a  matter  of  any  very 
great  importance. 


76  THE  SYNONYMS  AND  CLASSIFICATION 

The  Non-paralytic  or  Abortive  Form  and  Preparalytic  Stage. — 

Wickman,  in  his  marvelous  monograph,  divides  the  abortive  cases 
into  four  classes : 

1.  Those  with  the  course  of  a  general  infection. 

2.  Those  showing  meningeal  irritation. 

3.  Those  with  marked  pains  suggesting  an  influenza. 

4.  Those  with  accompanying  gastro-intestinal  distiu-bances. 
To  this  one  might  add  a  fifth,  for  the  purpose  of  calling  attention 

to  it,  of  an  anginal  form,  or  those  beginning  with  definite  sore 
throat. 

It  should  be  borne  in  mind  that  poliomyelitis  is  a  disease  which, 
probably  in  a  very  large  proportion  of  cases,  does  not  involve  the 
nervous  system  to  such  an  extent  as  to  cause  special  symptoms, 
and  the  cases  characterized  as  abortive  are  merely  those  which  go 
through  a  preparalytic  stage  without  having  any  definite  paralysis 
following.  If  this  point  is  borne  in  mind  it  simplifies  the  concep- 
tion and  also  the  description  of  these  cases,  for  what  is  true  of  the 
abortive  cases  is  equally  true  of  the  preparalytic  stage  of  the  ordi- 
nary form  of  the  disease.  Doubtless  a  great  number  of  the  so-called 
abortive  cases  have  muscular  weakness  or  even  paralysis  of  a  very 
limited  amount.  It  is  extremely  difficult  to  detect  even  marked 
differences  in  muscular  power  in  very  young  infants,  so  that  the 
lesser  degrees  of  loss  of  power  may  easily  escape  notice  even  after 
the  most  searching  and  repeated  examinations. 

In  the  New  York  epidemic  of  1916  the  symptoms  at  the  onset 
were  very  carefully  studied  in  1500  cases.    Figures  are  as  follows: 

Fever 806 

Nausea  and  vomiting 476 

Malaise  and  weakness 255 

Headache 205 

Constipation 148 

Irritability 125 

Diarrhea 122 

Coryza 78 

Rigidity  of  neck 74 

Tonsillitis 65 

Pharyngitis 57 

Peripheral  pain ^^    . 

Muscular  twitching 57 

Prostration 49 

Convulsions 47 

Cough 45 

The  onset  of  the  disease  is  usually  sudden.  Occasionally  the 
onset  is  gradual  and  it  may  not  be  possible  to  tell  exactly  when  the 


CLASSIFICATION  77 

child  was  taken  ill.  The  severity  of  the  initial  synij^torns  bear 
no  relation  whate\er  to  the  subsequent  course  of  the  disease,  as 
one  sees  a  very  mild  onset  followed  by  most  extensive  paralysis 
and  even  death,  and  other  cases  coming  in  a  most  fulminating 
manner  which  subsequently  clear  up  entirely.  The  first  thing 
observed  about  the  cliild  is  that  it  is  ill,  and  of  all  the  symptoms 
noted  fever  is  the  most  constant.  There  are,  perhaps,  exceptional 
cases  in  which  the  febrile  stage  is  slight  and  short  and  so  easily 
overlooked  by  ignorant  or  careless  parents;  but  in  cases  under  care- 
ful observation  the  afebrile  attacks  are  certainly  most  exceptional. 
The  second  most  notable  symptom  is  the  presence  of  pain,  and  in 
children  old  enough  to  locate  the  pain,  headache  is,  next  to  fever, 
the  commonest  symptom.  The  pains  may  be  in  any  part  of  the 
body  and  may  be  so  marked  as  to  overshadow  all  other  features  of 
the  disease,  or  they  may  be  so  trifling  as  to  be  only  elicited  by  special 
examination,  with  all  gradations  in  between.  The  commonest 
pain  next  to  headache,  and  of  decidedly  more  value  in  diagnosis, 
is  a  tenderness  and  pain  along  the  spine  and  down  the  legs  reaching 
to  the  heels  or  even  the  soles  of  the  feet,  and  another  very  common 
and  suggestive  pain  is  that  in  the  neck  and  back  of  the  head.  If 
the  head  is  bent  forward  this  is  usually  greatly  increased,  causing 
the  child  to  cry  out  and  resist  very  markedly.  If  there  is  not  much 
pain  present  it  can  usually  be  elicited  by  bending  the  legs  up  and 
the  head  forward,  so  as  to  flex  the  spine.  In  some  children  the  pain 
is  only  present  when  one  attempts  to  move  the  arms  or  legs  or 
various  parts  of  the  body;  in  others  it  is  spontaneous  and  the 
child  cries  most  of  the  time  with  it;  and  in  still  others  there  is  a 
hyperesthesia,  so  that  the  slightest  touch  without  any  movement 
whatever  elicits  an  unusual  degree  of  suffering.  In  some  cases  pain 
is  elicited  on  gently  squeezing  the  muscles.  In  many  cases  there  is 
slight  stifl'ness  of  the  neck  and  the  child  assumes  a  very  suggesti^'e 
attitude,  lying  on  one  side  or  the  other,  but  not  on  the  back,  so  that 
the  head  may  be  thrown  slightly  backward.  The  legs  are  usually 
drawn  up,  although  not  always.  The  disease  may  be  ushered  in 
with  a  convulsion,  or  convulsions  may  occur  in  the  course  of  the 
disease. 

The  mental  condition  is  extremely  interesting.  The  commonest 
form  of  disturbance  consists  of  very  marked  drowsiness,  which  is 
replaced  by  a  most  extraordinary  irritability  when  the  child  is 
aroused;  but  when  one  ceases  to  examine  him  he  rolls  over  into  his 
former  position  and  dozes  ofif  again.    Other  children  are  extremely 


78  THE  SYNONYMS  AND  CLASSIFICATION 

restless  and  irritable  and  some  are  wide-awake  with  a  hyperacute 
mentality  or  what  has  been  called  alert  cerebration.  With  this  is 
a  very  evident  delirium  or  a  tendency  to  delirium.  These  cases,  in 
our  experience,  are  of  the  worst  possible  type  and  usually  die.  In 
some  children  there  is  a  very  marked  delirium — talking,  muttering^- 
and  this  is  accompanied  by  a  tendency  to  move  about  in  the  bed 
and  change  the  position  frequently.  Often  the  moving  about  is 
exceedingly  suggestive,  the  child  tossing  from  side  to  side  and  not 
lying  in  any  position  more  than  a  few  moments,  sitting  up,  standing 
up,  and  half-turning  from  side  to  side  in  a  perfectly  purposeless 
way.  If  the  child  is  watched  carefully  it  will  very  often  be  seen  to 
have  fibrillary  twitching  of  the  muscles;  at  other  times  whole  muscles 
will  tremble.  In  rare  instances  the  muscle  is  more  or  less  spastic 
and  may  stiffen  when  the  extremity  is  taken  hold  of  to  relax  a  few 
moments  later. 

The  gastro-intestinal  symptoms  are  not  uncommon.  Anorexia 
is  the  rule.  Vomiting  may  be  present  and  may  be  so  marked  as  to 
suggest  an  acidosis.  Constipation  is  rather  more  common  than 
diarrhea,  but  the  latter  is  frequently  met  with.  The  throat  is 
often  reddened;  the  redness  is  general  and  not  limited  to  the  ton- 
sils, and  in  some  cases  there  is  a  considerable  amount  of  coryza 
and  slight  suffusion  of  the  eyes.  Another  curious  feature  met  with 
both  early  and  later  on  in  the  disease  is  the  tendency  to  profuse 
sweating.  This  may  be  as  marked  as  the  colliquative  sweats  seen 
in  typhoid.  Sometimes  the  sweating  is  limited  to  one  part  of  the 
body,  as  to  the  face  or  neck,  or  to  one  extremity,  sometimes  to 
one-half  of  the  face.  In  some  cases  there  may  be  retention  of  the 
urine,  and  this  should  always  be  looked  for. 

Usually,  as  Wickman  has  suggested,  the  disease  presents  certain 
dominant  features.  The  cases  which  are  like  the  course  of  a  general 
infection  have  nothing  to  suggest  the  diagnosis,  or  they  may  have 
some  of  the  things  mentioned  above,  the  general  history  of  the 
attack  being  that  the  child  is  taken  ill  suddenly  with  an  attack  of 
vomiting  follow^ed  by  a  fever  of  from  101°  to  103°  or  104°,  or  some- 
times higher,  with  headache,  and  feeling  very  badly,  but  without 
any  definite  symptoms  of  any  kind.  This  may  clear  up  in  twenty- 
four  hours,  or  it  may  last  two,  three,  or  rarely  four  days,  when  the 
symptoms  disappear  entirely  and  the  child  has  nothing  whatever 
to  show  for  it.  These  cases  may  be  seen  in  connection  with  two  or 
three  or  more  cases  in  a  family  or  group  of  children,  and  the  diag- 
nosis is  made  or  suspected  by  the  fact  that  the  child  was  taken  ill 


CLASSIFICATION  79 

at  the  same  time  with  identical  symptoms  or  nearly  so,  to  one  or 
more  definite  cases  of  the  disease  in  the  immediate  surroundings. 
These  cases  present  the  greatest  difficulty  in  diagnosis. 

The  meningeal  form  is  the  most  suggesti\'e  of  all,  and  one  almost 
immediately  realizes  that  he  has  either  to  do  with  a  beginning 
poliomyelitis,  a  meningitis,  or  a  meningismus.  In  these  cases,  when 
the  patient  is  examined,  it  will  be  found  that  there  is  an  anterior 
and  posterior  stiffness  of  the  neck;  Kernig's  sign  may  be  present 
or  absent;  INIcE wen's  sign,  elicited  by  percussing  and  auscultating 
the  cranium,  may  be  present,  owing  to  the  distention  of  the  ven- 
tricles of  the  brain  with  the  fluid;  and  the  patient  may  show  a  very 
characteristic  sign  at  this  time,  or  usually  a  little  later,  which  may 
be  described  as  follows:  If  the  patient  is  raised  by  placing  the 
hands  under  the  shoulders  the  head  will  fall  back.  If  the  child  is 
told  to  raise  the  head  when  it  is  sufficiently  conscious,  it  will  do  so 
and  hold  it  forward  a  moment  or  so  and  the  head  will  again  fall 
back.  This  is  a  sign  of  very  great  importance.  Brudzinski's  neck 
sign  may  be  present.  The  arms  and  legs  are  flexed  on  the  trunk 
to  theii*  full  extent  and  the  head  is  passively  flexed  on  the  chest. 
The  patient  utters  a  cry.  Brudzinski's  leg  sign  often  may  be  elic- 
ited. One  leg  is  passively  flexed  on  the  abdomen  to  its  full  extent 
when  the  other  leg  is  drawn  up  by  the  patient.  In  some  cases  there 
is  a  cujious  vasomotor  distiu-bance  which  is  most  often  seen  in  the 
cases  of  the  meningeal  form.  This  consists  of  an  alternate  blush- 
ing and  paling  of  various  areas  of  the  skin.  It  may  be  over  small 
spots  or  over  large  areas,  the  part  aftected  being  redder  than  nor- 
mal, and  then  after  a  varying  time  it  may  become  paler  than  the 
surrounding  skin  or  present  a  normal  appearance.  Sometimes  the 
flushing  is  A'ery  transient  and  is  only  a  momentary  wavering  flood- 
ing of  the  superficial  vessels.  A  fine  intentional  tremor  is  frequently 
noted  and  is  often  of  help  in  diagnosis.  There  is  practically  never 
any  question  in  these  cases  with  a  meningeal  irritability  of  the 
advisability  of  a  lumbar  punctiu-e,  and  it  should  be  done  as  soon 
as  possible,  and  this  usually  clears  up  the  diagnosis  immediately. 

The  cases  with  marked  pain,  resembling  influenza,  should  suggest 
poliomyelitis.  In  our  experience  we  have  rarely  seen  cases  of  influ- 
enza w4th  as  much  pain,  or  the  kind  of  pain,  as  described  above, 
although  they  do  occur.  In  these  cases  a  lumbar  puncture  should 
be  done  to  settle  the  question  of  diagnosis. 

The  gastro-intestinal  cases  are  more  difficult  because  one  does 
not  always  have  in  mind  the  possibility  of  a  poliomyelitis.     The 


80  THE  SYNONYMS  AND  CLASSIFICATION 

child  is  taken  with  a  fever  with  intense  vomiting,  and  if  it  has  had 
a  history  of  acidosis  with  vomiting  before  this  the  physician  may 
be  thrown  oflF  his  guard.  In  some  of  these  cases,  if  the  child  is  care- 
fully observed,  some  of  the  special  features  mentioned  above  may 
be  elicited,  but  if  they  are  absent  the  diagnosis  may  be  impossible. 
The  presence  of  a  very  marked  diacetic  reaction  in  the  urine  will 
incline  one  to  believe  that  the  case  is  one  of  acidosis,  though  it  must 
be  borne  in  mind  that  any  febrile  condition  will  show  diacetic  acid 
in  the  urine,  although  the  reaction  is  not  as  marked. 

The  cases  with  sore  throat  and  coryza  are  also  difficult  and  prac- 
tically impossible  to  tell  unless  a  careful  examination  elicits  some 
suggestive  symptoms  or  signs. 

This  preparalytic  stage,  when  it  does  not  go  on  to  the  develop- 
ment of  a  paralysis,  is  what  we  have  called  an  abortive  case,  and 
may  subside  in  twenty-four  hours,  or  it  may  last  two,  three,  or  four 
days,  occasionally  five,  six,  seven,  or  eight  days,  in  a  few  instances 
longer,  but  rarely.  In  some  of  these  cases  the  convalescence  may 
be  slow  and  the  child  may  suffer  with  indefinite  symptoms  for  days 
or  even  weeks  after  the  attack.  These  consist  chiefly  of  pain  com- 
ing on  at  any  time,  but  more  often  at  night,  sometimes  waking  the 
child  up  out  of  sleep.  These  pains  are  usually  transient  and  disap- 
pear either  spontaneously  or  after  rubbing  the  affected  parts.  In 
some  instances  the  pain  is  accompanied  with  cramps  in  the  muscles. 
The  child  may  tire  readily  on  exertion  even  though  it  has  shown 
no  paralysis  or  loss  of  power,  or  the  tiring  may  be  localized  to  cer- 
tain groups  of  muscles  or  to  one  extremity.  When  this  is  the  case 
one  might  assume  that  the  spinal  cells  supplying  this  part  have 
been  affected.  If  the  child  is  old  enough  to  make  special  tests  of 
the  power  of  the  muscles  according  to  the  method  suggested  by 
Lovett,  the  diagnosis  may  be  even  more  certain. 

The  Ataxic  Cases. — These  form  an  interesting  group  and  Medin, 
in  his  study  noted  five  cases  in  which  there  was  a  transitory  ataxia 
during  early  convalescence.  In  four  of  these  there  were  muscular 
spasms  and  tremors  in  the  acute  stage  of  the  disease.  In  almost 
all  his  cases  there  was  no  atrophy  of  the  muscles  and  often  increased 
patellar  reflexes.  Curious  association  of  other  things  may  be  met 
with  in  the  ataxic  cases.  There  may  be  temporary  disturbances  of 
speech,  probably  due  to  either  bulbar  lesions  or  changes  in  the 
peripheral  nerves;  the  patient  may  stutter  or  stammer,  have  diffi- 
culty in  enunciating,  and  the  voice  sounds  thick  and  indistinct. 
Netter  has  described  a  case  which  was  associated  with  ataxia, 


CLASSIFICATION  81 

aphasia  and  paralysis  of  the  right  arm,  and  Xonno  saw  a  case  of 
status  hemiepilepticus  and  this  was  followed  by  a  general  ataxia 
of  the  cerebral  type.  The  pathological  changes  in  these  cases  has 
not  been  sufficiently  studied.  It  is  possible  that  the  lesion  may  be 
either  in  the  brain  or  cerebellum,  in  the  pyramidal  tracts  or  in 
Clarke's  columns.  Rissler  had  an  opportunity  of  studying  a  fatal 
case  and  found  degeneration  of  the  cells  in  Clarke's  columns.  Medin 
suggested  the  great  similarity  between  the  clinical  picture  of  these 
cases  and  the  so-called  polyneuritic  cases  and  that  the  condition 
may  be  brought  about  in  some  cases  by  changes  in  the  peripheral 
sensory  nerves,  although  as  far  as  we  know  this  has  not  been  actu- 
ally demonstrated.  He  described  the  ataxia  as  resembling  the  ataxia 
like  that  seen  in  hereditary  ataxia  and  not  at  all  as  that  of  a  tabetic. 
The  patient  totters  and  staggers,  falls  easily,  walks  with  the  legs 
wide  apart  and  has  great  trouble  in  maintaining  his  equilibrium. 
Cases  have  been  described  of  a  very  distinctly  cerebellar  type 
in  which  there  were  almost  always  involvement  of  some  of  the 
cranial  nerves.  Cerebellar  ataxia  is  characterized,  as  Duchenne,  of 
Boulogne, suggested,  by  a  sort  of  drunkenness  of  movement  and  inco- 
ordination. The  patient  has  a  sort  of  vertigo  and  in  standing  totters 
from  side  to  side  and  has  difficulty  in  maintaining  the  equilibrium 
and  is  unable  to  stand  on  one  leg.  In  walking  the  patient  staggers 
like  a  drunken  man,  places  the  feet  uncertainly  and  cannot  follow 
a  straight  line.  Ataxia  in  all  instances  seems  to  be  transitory,  and 
few  of  these  cases  have  ended  fatally. 

Medin  described  certain  cases  in  which  ataxia  was  one  of  the 
most  prominent  symptoms.  The  following  are  two  clinical  histories 
from  his  remarkable  study: 

"A  boy,  aged  three  years  and  one  month,  was  taken  sick  on 
August  25  with  a  high  fever,  restlessness,  irritability,  sleeping 
little,  and  having  previously  spoken  distinctly  and  well,  commenced 
to  talk  indistinctly  in  a  thick  voice.  At  the  beginning  the  move- 
ments were  made  freely  and  with  no  twitching,  but  there  was 
trembling  of  the  legs  in  walking.  At  the  end  of  several  days 
he  was  somnolent  and  refused  to  walk  because  it  caused  pain 
in  the  legs,  and  he  complained  when  he  was  touched.  On  Septem- 
ber 2,  the  note  was  made  that  he  seemed  a  little  heavy,  wished  to 
remain  in  bed  and  sleep  and  complained  when  he  was  touched  and 
did  not  wish  to  sit  up  or  lie  on  the  right  side.  He  could  move  the 
extremities  without  any  strength.  When  he  was  forced  to  walk 
he  complained,  walked  with  difiiculty,  staggered  behind  his  mother 
6 


82  THE  SYNONYMS  AND  CLASSIFICATION 

when  she  walked  before  him,  but  no  signs  of  any  direct  ordinary 
sensations.  The  patellar  reflexes  were  absent  and  the  muscles 
did  not  react  to  the  faradic  current.  The  legs  were  more  cold 
than  the  rest  of  the  body.  On  September  7  he  was  less  sleepy, 
the  examination  remained  as  above,  but  the  patellar  reflexes  were 
present  and  he  had  had  difficulty  throughout  the  illness  in  having 
bowel  movement.  September  1 1  he  could,  perhaps,  walk  somewhat 
better,  but  with  paretic  gait,  with  a  tendency  to  spastic  move- 
ments; no  patellar  reflexes.  September  16,  general  condition  better, 
walks  better,  there  is  no  atrophy,  patellar  reflexes  marked  on  right 
side,  cannot  be  elicited  on  left.  September  23,  walks  better,  more 
firmly,  but  with  distinct  weakness  of  the  right  leg.  Patellar  reflexes 
distinct  on  both  sides,  but  more  marked  on  the  right.  September 
30,  paralysis  scarcely  noticeable  in  the  right  leg.  October  16,  walks 
perfectly  well  and  is  in  good  health.  Diagnosis:  infantile  paralysis, 
probably,  and  acute  polyneuritis." 

"In  the  other  history  of  a  similar  condition,  it  is  of  a  boy,  aged 
three  years  and  seven  months,  taken  sick  on  September  4. 
He  had  always  had  feeble  health  and  two  years  before  had 
pneumonia  following  whooping-cough.  His  parents,  brothers  and 
sisters  were  perfectly  healthy.  He  had  headache,  pain  in  the  throat, 
movements  of  the  face.  Became  worse  in  the  following  days  and 
was  very  somnolent.  This  increased  until  he  was  no  longer  able 
to  recognize  people  about  him.  September  8,  violent  piercing 
cries,  no  convulsions;  no  vomiting.  September  9,  somnolent,  cries 
sometimes  as  if  in  pain,  especially  if  one  tries  to  turn  him;  sometimes 
he  strikes  out  in  different  directions  with  his  arms  with  certain 
movements,  but  lies  with  the  legs  a  little  contracted,  but  moves 
them  about  also  in  quiet  fashion.  He  cannot  stand  or  walk.  Holds 
his  head  bent  backward,  but  can  move  his  head  perfectly.  There 
is  no  hyperesthesia  of  the  skin.  Has  a  fixed  stare  without  any 
expression.  If  he  is  wakened  looks  fixedly  at  objects.  No  stra- 
bismus, pupils  of  equal  size;  will  not  make  any  answer  when  one 
speaks  to  him.  September  10,  twitching  of  the  tongue  and 
choreiform  movements  of  the  right  arm.  September  11,  a 
general  convulsion  during  the  night  and  nystagmus;  twitching  of 
the  mouth  and  of  the  lower  jaw;  tonic  cramps  of  the  extremities; 
very  somnolent  and  at  the  same  time  holds  his  head  straight.  Is 
very  agitated  and  cries  and  throws  himself  about  as  noted  before; 
evidently  cannot  speak;  nothing  else  abnormal  except  a  red  throat. 
September  12,  free  from  fever^  less  agitated,  less  somnolent,  replies 


CLASSIFICATION  83 

'Yes'  or  'Xo/  but  very  indistinctly;  has  no  nystagmus  and  the 
twitching  of  the  tongue  and  face  is  less.  The  following  days  the 
temperature  remained  normal,  the  somnolence  ceased  and  the  child 
became  much  more  tranquil,  the  twitching  of  the  face  and  tongue 
stopped;  there  is  a  convergent  strabismus,  but  it  was  impossible 
to  tell  of  what  sort  owing  to  the  child  being  frightened.  Septem- 
ber 18,  child  could  speak  especially  clearly,  cried  easily,  but 
evidently  without  pain,  understood  what  was  said  to  him  and 
recovered  his  memory,  seized  objects  with  the  hand,  but  trembled 
sometimes,  cannot  walk  alone,  and  has  to  be  supported  by  both 
hands,  and  in  spite  of  that,  often  falls,  movements  of  the  legs  are 
hesitating;  patellar  reflexes  of  the  legs  are  exaggerated  and  there 
is  ankle- clonus,  but  no  h^-peresthesia.  September  30,  condition 
was  very  much  improved,  according  to  the  opinion  of  the 
mother.  He  was  able  to  talk  as  in  former  days,  there  was  no 
strabismus,  no  atrophy  and  no  lowering  in  the  temperatiu"e  that 
one  could  make  out.  Movements  of  the  arms  entirely  free  and  his 
walk  was  uncertain  and  hesitating.  October  11,  was  able  to  walk 
without  difficulty  and  was  apparently  completely  restored  to 
health." 

Transient  Ataxia. — Peabody,  Draper  and  Dochez  have  called 
attention  to  a  very  interesting  condition  seen  in  cases  where  the 
lesion  is  definitely  limited  to  the  cervical  cord,  the  legs  not  being 
paralyzed.  In  these  cases  it  seemed  very  probable  that  the  upper 
neuron  was  affected,  either  the  pjTamidal  tracts  or  Clarke's  column 
where  they  passed  through  the  cervical  region,  and  that  resulted  in 
a  tendency  to  hold  the  legs  stiffly  with  increased  knee  and  ankle 
reflexes  and  a  transient  spastic  ataxia. 

The  Cerebral  Tjrpe. — There  is  a  rare  form  of  the  disease  known 
as  the  cerebral  or  encephalitic  form,  or  polioencephalitis,  in  which 
the  lesion  involves  the  upper  motor  neuron,  either  alone  or  chiefly. 
This  leads  to  a  paralysis  of  the  spastic  tj'pe  ^-ith  increased  reflexes 
and  no  reaction  of  degeneration.  This  form  of  the  disease  is  appar- 
ently very  rare  and  should  not  be  confused  with  cases  that  have, 
of  recent  years,  been  described  under  these  terms  in  which  the 
chief  lesion  was  in  the  lower  motor  neiu-on  with  consequent  'flaccid 
paralysis,  the  cases  being  described  as  cerebral  owdng  to  the  pres- 
ence of  coma  or  s^'mptoms  suggesting  meningitis.  One  may  get 
some  idea  of  the  infrequency  of  the  true  cerebral  form  when  one 
considers  that  ^Yickman,  in  the  Swedish  epidemic  in  1905,  in  over 
1000  cases  did  not  see  a  single  instance.    Xor  was  any  reported  in 


84  THE  SYNONYMS  AND  CLASSIFICATION 

the  New  York  epidemic  of  1907,  in  which  over  2000  cases  were 
observed.  Peabody,  Draper  and  Dochez  did  not  meet  with  any  in 
their  study.  Zappert,  in  555  cases,  however,  describes  5,  and  various 
other  authors  have  contributed  one  or  more  cases.  The  first  accu- 
rate description  was  given  by  StriimpelP  in  a  lecture  in  Leipzig  in 
1884.  He  called  this  condition  polioencephalitis  and  noted  that 
in  both  diseases  the  chief  site  of  the  lesion  is  the  gray  matter  of  the 
anterior  horn  in  one,  and  in  the  other  in  the  corresponding  portion 
of  the  cerebral  cortex;  and  in  considering  the  etiology  he  remarked: 
"After  all,  one  can  but  ask  if  all  the  differences  based  on  purely 
anatomical  reasons  between  neuritis,  polyneuritis  and  acute  infan- 
tile encephalitis,  is  not  artificial.  For  my  own  part,  I  am  of  the 
opinion  that  all  the  above-mentioned  affections  are  the  same  from 
the  point  of  view  of  etiology  and  are  only  to  be  regarded  as  different 
localized  manifestations  of  a  specific  disease  or  caused,  at  least,  by 
forms  superficially  closely  related." 

Vizioli^  had  previously  noted  the  close  relationship  of  certain 
cerebral  paralyses  in  children  to  the  spinal  form  of  the  disease  and 
the  symptom-complex  was  also  described  by  Pierre  Marie  in  France. 
StriJmpell  described  24  cases  all  under  six  years  of  age  and  19  of 
these  were  under  four  years  of  age,  but  while  most  of  the  cases  have 
been  in  young  children  it  should  not  be  forgotten  that  cases  have 
been  described  in  adults. 

The  onset  in  the  cerebral  cases  is  very  similar  to  that  seen  in 
the  ordinary  form,  the  most  pronounced  symptom  being  convul- 
sions, vomiting  and  fever.  It  has  sometimes  been  said  that  a  case 
coming  on  with  convulsions  is  liable  to  be  of  the  cerebral  type  and 
while  most  of  the  cerebral  cases  that  have  been  described  have  had 
convulsions  at  the  onset,  it  by  no  means  follows  that  a  chill  or 
convulsion  means  a  case  must  necessarily  develop  in  a  certain 
way.  Most  of  the  cases  that  have  been  described  have  been  cere- 
bral from  the  onset,  but  in  some  there  have  been  prodromes  lasting 
nearly  two  or  three  days  after  which  the  nature  of  the  disease 
becomes  manifest.  There  have  been  instances,  however,  in  which 
the  prodromal  stage  lasted  several  weeks,  during  which  time  there 
have  been  convulsive  seizures  and  then  finally  paralysis  of  a  defi- 
nitely cerebral  type.  The  resulting  paralysis  may  be  a  hemiplegia 
or  a  monoplegia  and  there  may  be  involvement  of  the  face.  Facial 
paralysis  is  less  frequent  than  the  other  forms.    In  some  instances 

1  Jahrb.  f.  Kinderh.,  1885,  p.  173. 

2  Deir  Emiplegia  spastico  Infantile  (Heine),  Morgagni,  Napoli,  1880,  xxii,  568. 


CLASSIFICATION  85 

there  is  strabismus.  The  paralysis  usually  improves,  but  generally 
leaves  behind  it  a  certain  amount  of  loss  of  power  and  a  tendency 
to  contraction.  The  paralysis  is,  of  course,  spastic  in  character 
and  the  reflexes  are  exaggerated.  There  is  no  atrophy  and  there 
is  no  reaction  of  degeneration.  Cases  have  been  described  in  which 
there  was  ataxia  without  paralysis.  Some  of  these  patients  may 
recover  more  or  less  entirely  or  even  entirely,  as  noted  by  INIedin, 
but  there  is  a  distinct  tendency  to  have  signs  of  motor  irritation 
later  on.  The  late  disturbances  are  usually  either  a  general  epi- 
lepsy' or  sometimes  epileptic  convulsions  limited  to  the  paralyzed 
member;  sometimes  there  is  mental  deterioration,  sometimes  moral 
deterioration,  and  sometimes  speech  disturbances  or  combinations 
of  these,  i^thetosis,  particularly  of  the  hands,  is  perhaps  the  most 
common  of  the  sequelae.  INIedin,^  in  his  remarkable  article,  described 
4  cases  of  this  type,  2  of  which  had  involvement  of  the  sixth 
nerve,  indicating  involvement  of  the  pons  as  well  and  giving  the 
connecting  link  between  the  cerebral  and  the  spinal  forms,  and  it  is 
of  particular  importance  to  know  that  these  were  observed  in  the 
same  epidemic.  As  an  instance  of  the  acute  form  T^•ith  entire 
recovery  we  may  quote  the  following  case  described  by  Medin: 

"A  girl,  aged  two  and  a  half  years,  was  taken  sick  on  September 
8  with  fever  and  vomiting.  Was  constipated  for  the  following 
two  days,  but  otherwise  apparently  well  until  September  12,  when 
in  the  evening  she  became  agitated  and  had  fever.  The  next  morn- 
ing she  remained  in  bed  with  sore  throat  and  pains  in  the  right  big 
toe.  She  got  weaker  and  had  trembling  in  the  extremity  on  the 
right  side.  In  the  evening  she  had  paralysis  of  the  arm  and  leg  on 
the  right  side,  but  still  could  make  incoherent  movements.  She 
sighed  frequently,  had  flushed  face,  was  somnolent,  sensitive  over 
the  entire  body,  and  had  some  difBculty  in  lu-ination.  The  fever 
persisted  for  several  days;  she  stammered,  having  previously  spoken 
perfectly  well;  the  reflexes  were  normal.  She  had  difficulty  in 
taking  hold  of  things  with  the  right  hand,  movements  of  which 
were  uncertain;  she  dragged  the  right  leg.  On  September  18  the 
fever  had  disappeared,  general  condition  was  as  before,  but  the 
reflexes  of  the  right  arm  and  leg  were  exaggerated.  She  spoke  as 
before,  and  there  was  no  uncertainty  in  the  movements  of  the 
right  arm.  On  September  21  she  was  well,  talkative,  limped  a  little 
with  the  right  leg,  and  the  patellar  reflex  on  that  side  was  exagger- 

1  Arch,  de  med.  des  Enfants,  1S9S,  i,  257  and  321. 


86  THE  SYNONYMS  AND  CLASSIFICATION 

ated.  She  had  made  a  rapid  complete  recovery  without  any  symp- 
toms remaining." 

During  the  Baltimore  epidemic  in  1916  we  noted  one  possibly 
doubtful  case  which  recovered  entirely.  The  patient  was  sixteen 
months  old,  was  admitted  on  October  15  to  the  Children's  Hospital 
School.  At  this  time  the  note  was  made  that  "she  is  a  poorly 
developed  child,  lying  in  bed  without  apparent  discomfort.  She 
is  irritable,  seems  quite  conscious,  and  can  stand  with  assistance, 
but  bears  the  weight  on  the  right  foot,  holds  up  the  head  well,  but 
will  not  sit.  Has  no  apparent  hyperesthesia.  Pupils  equal,  react 
to  light  movements,  and  the  eye  normal.  Neck  somewhat  stiff; 
Kernig's  sign  positive.  The  arms  move  perfectly  well  and  the 
right  leg  seems  perfectly  normal.  The  left  quadriceps  is  weak, 
but  not  entirely  paralyzed.  The  reflexes  of  biceps,  abdomen,  and 
ankle  can  be  elicited  on  both  sides.  Triceps  could  not  be  elicited. 
Patellar  present  on  the  right  side  and  absent  on  the  left."  She  sub- 
sequently developed  a  curious  spasticity  of  both  legs;  the  muscles 
were  not  atrophied,  "but  as  soon  as  the  leg  is  taken  hold  of  there 
is  a  marked  spasticity,  which  varied  from  time  to  time,  and  seemed 
almost  voluntary,  but  which  on  careful  study  apparently  is  not." 
By  the  end  oi  October  she  was  able  to  walk  with  a  little  assistance, 
could  sit  up  in  bed,  had  regained  her  normal  mental  condition,  and 
was  perfectly  contented.  The  spasticity  disappeared  almost  entirely 
during  the  few  succeeding  weeks,  and  the  patient  left  the  hospital 
apparently  entirely  recovered. 

The  lesions  in  these  cases  have  been  described  in  a  few  instances, 
and  while  scattered  lesions  in  the  cerebrum  have  been  frequently 
described  in  the  a^utopsy  findings  of  poliomyelitis,  extensive  foci 
have  been,  on  the  whole,  rare.  Harbitz  and  Scheel  had  an  oppor- 
tunity of  studying  the  brain  of  a  man,  aged  thirty-nine  years,  in 
whom  the  disease  began  with  headache,  fever,  and  excessive  sweat- 
ing. A  few  days  later  he  had  general  convulsions,  delirium,  stiff- 
ness of  the  neck,  and  vomiting,  and  in  fojir  days  paralysis  of  the 
left  hyperglossal,  rigidity  of  the  extremities,  and  increased  patellar 
reflexes,  with  twitching  of  the  left  forearm  and  fingers  later.  The 
patient  was  comatose  and  died  on  the  thirteenth  day  of  the  disease. 
There  was  inflammation  and  softening  of  the  right  temporal  lobe, 
and  the  microscopic  study  showed  the  same  histological  changes 
that  have  been  described  in  the  cord  in  poliomyelitis.  They  also 
studied  a  case  in  a  child,  aged  seven  years,  in  whom  the  onset  was 
sudden,  with  fever,  vomiting,  drowsiness,  rigidity  of  the  neck,  and 


CLASSIFICATION  87 

twitching  of  the  arms  and  legs.  The  child  died  in  four  days  and  the 
only  microscopic  lesions  were  hyperemia  in  the  acqueduct  of  Syl- 
vius and  of  the  cervical  part  of  the  cord  and  an  acute  encephalitis 
of  the  left  optic  thalamus.  Both  cases  were  seen  in  the  Norwegian 
epidemic  of  1905  in  Christiania.  At  this  time  only  13  cases  of  acute 
poliomyelitis  were  reported  in  that  city,  but  it  seems  certain  that 
these  were  immistakable  cases  of  the  cerebral  form  of  the  disease. 
As  miglit  be  expected  the  lesions  are  not  ahva}'s  limited  to  the  upper 
motor  neuron  but  ma}'  occur  most  anywhere.  There  have  been 
series  of  instances  in  which  there  was  a  combination  of  the  flaccid 
and  spastic  paralysis.  Such  cases  have  been  reported  by  Wickman, 
Pierre  Marie,  Oppenheim,  Neurath  and  others.  Mobius  has 
described  a  brother  and  a  sister  taken  ill  at  almost  the  same  time 
with  a  febrile  affection.  In  one  there  was  a  spastic  hemiplegia  with 
choreiform  mo\'ements;  in  the  other  flaccid  paralysis.  There  can 
be  no  doubt  about  the  identity  of  these  cases  and  the  other  forms  of 
poliom}'elitis  as  regards  etiology,  and  yet  the  final  test  must  come 
by  reproducing  the  disease  in  monkeys  with  virus  taken  from  a 
fatal  cerebral  case.  As  far  as  we  know  it  has  not  been  done  up  to 
the  present  time.  Frost  and  Anderson^  reported  an  instance  in 
which  a  flaccid  paraplegia  subsequently  became  spastic  and  the 
blood  of  this  patient  showed  the  presence  of  antibodies  protective 
against  the  virus  of  poliomyelitis.  It  is  curious  to  note  in  connec- 
tion with  this  form  of  the  disease  that  the  disease  as  produced 
experimentally  in  monkeys,  even  if  the  inoculation  is  made  intra- 
cerebrally  shows  a  spinal  paralysis. 

The  Meningeal  Form. — Signs  of  meningeal  irritation  are  common 
in  poliomyelitis,  so  much  so  that  La  Fetra  thinks  in  making  the 
diagnosis  one  should  alwaj's  look  for  such  signs.  At  times,  however, 
the  picture  of  meningitis  may  be  so  marked  as  to  actually  obscure 
the  real  nature  of  the  disease,  unless  one  is  thoroughly  familiar 
W'ith  the  fact  that  poliomyelitis  may  at  times  resemble  menin- 
gitis so  closely  as  to  test  the  diagnostic  skill  of  even  the  best  clini- 
cians, and  many  times  to  defy  diagnosis  without  a  lumbar  puncture 
and  examination  of  the  cerebrospinal  fluid.  The  patient  may  have 
meningeal  s}inptoms  from  the  onset,  or  the  disease  may  start  in 
the  usual  manner  and  sjniptoms  of  meningitis  come  after  two,  three, 
or  four  days.  As  a  general  rule,  the  symptoms  of  meningeal  ii'ri- 
tation  clear  up  in  a  few  days  or  else  the  patients  die;  but  in  some 

1  Jour.  Am.  Med.  Assn.,  1911,  Ivi,  663. 


88  THE  SYNONYMS  AND  CLASSIFICATION 

the  condition  may  drag  along  so  that  it  resembles  more  and  more 
closely  tuberculous  meningitis.  The  appearance  may  be  exactly 
like  a  tuberculous  meningitis,  while  other  cases  bear  close  resem- 
blance to  cerebrospinal  fever. 

At  the  onset  there  is  vomiting  and  headache;  the  patient  com- 
plains of  pain,  has  rigidity  of  the  neck,  opisthotonos,  Kernig's  sign 
is  present,  and  Babinski's  sign  may  be  present,  that  is,  irritating 
the  sole  of  the  foot  causes  extension  of  the  toes  instead  of  flexion. 
There  is  usually  strabismus  and  sometimes  tonic  or  clonic  spasms, 
either  localized  or  general.  There  is  the  usual  vasomotor  disturb- 
ance, the  tache  cerehrale  may  be  present,  there  may  be  flushing  or 
paling  of  the  skin.  There  is  often  fibrillary  twitching  of  the  muscles. 
A  lumbar  puncture  generally  clears  up  the  nature  of  the  condition, 
and  description  of  the  changes  in  the  fluid  will  be  found  under 
that  heading. 


Fig.  21. — Opisthotonos  in  the  meningeal  type. 

The  Polyneuritic  Form. — Cases  of  this  kind  have  been  described 
by  numerous  writers,  by  Medin  and  Wickman  in  Sweden,  by  Netter 
in  France,  by  Sachs  in  New  York,  and  many  others.  The  chief 
interest  in  this  form  is  in  its  resemblance  to  a  multiple  neuritis. 
Wickman  suggested  that  these  cases  may  probably  be  called,  more 
correctly,  pseudoneuritic,  inasmuch  as  there  is  apparently  no  inflam- 
mation of  the  nerves  at  autopsy,  although  it  is  true  that  compara- 
tively few  reports  have  been  made  upon  this  subject.  The  chief 
feature  of  the  disease  is  the  pain,  which  is  chiefly  along  the  nerve 
trunks,  and  which  may  be  most  intense  in  character.  The  origin 
of  this  pain  is  probably  due  to  changes  in  the  nerve  roots  or  the 
spinal  ganglia,  or  the  changes  in  the  cord.  There  does  not  seem 
to  be  any  connection  whatever  between  the  amount  of  pain  and  the 
amount  of  paralysis.  Some  of  the  cases  with  the  greatest  amount 
of  pain  may  be  paralyzed  very  little  or  not  at  all,  whereas  others 
with  comparatively  little  pain  may  suffer  from  severe    paralysis. 


CLASSIFICATION  89 

The  paralysis  may  be  recovered  from  entirely,  in  which  case,  of 
course,  it  makes  it  resemble  a  multiple  neuritis  more  closely.  In 
some  cases  there  may  be  a  combination  of  pain  and  ataxia,  there 
may  be  pain  along  the  nerve  trunks  after  the  acute  symptoms  of 
the  disease  have  subsided,  although  this  is  not  very  common.  The 
disturbances  of  sensation  have  not  been  very  carefully  studied, 
and  apparently  are  not  marked.  The  age  of  the  patients  precludes 
any  accurate  observations  being  made,  although  some  have  been 
made  in  cases  sufficiently  old  enough  to  respond  to  the  test  for  the 
various  forms  of  sensations.  The  differential  diagnosis  is  given 
under  the  heading  of  Diagnosis. 

The  Ascending  Type,  Resembling  Landry's  Paralysis. — In  1859 
Landryi  described  a  case  of  ascending  paralysis  of  a  few  weeks' 
duration,  with  certain  special  features  which  led  to  his  name  being 
associated  with  this  type  of  paralysis. 

Landry  gives  the  following  summary  of  his  case,  which  is  reported 
in  full:  "A  man,  aged  forty-three  years,  of  a  delicate  constitution, 
already  weakened  by  a  successive  series  of  acute  troubles,  by  the 
emission  of  blood,  under  prolonged  diet,  experienced,  during  a  slow 
and  incomplete  convalescence,  a  feeling  of  general  weakness  which 
gradually  increased,  but  without  any  appreciable  symptoms  of 
paralysis.  Soon  there  was  formication  of  the  toes  and  fingers,  first 
limited  to  these  parts  and  without  any  disturbance  of  motility. 
After  a  period  of  about  six  weeks,  characterized  by  these  phenomena, 
the  formication  of  the  extremities  extended  little  by  little  up  the 
members  and  was  replaced  by  a  heaviness  and  then  by  a  paralysis 
of  the  parts,  one  after  the  other.  The  paralysis,  which  affected 
only  the  motility,  extended  rapidly  from  the  feet  to  the  rest  of  the 
legs  and  then  to  the  arms,  to  the  trunk,  to  the  respiratory  muscles, 
to  the  tongue,  etc.  The  abolition  of  movement  was  so  complete 
that  he  could  no  longer  move  the  extremities.  Urination  and 
defecation  remained  normal  up  to  the  last  moment.  The  rigidity 
of  the  muscles  and  the  excitability  was  in  no  way  affected.  There 
were  no  contractions,  no  convulsions,  either  partial  or  complete, 
no  fibrillary  tremor,  no  reflex  movements.  At  no  time  did  the 
patient  complain  of  pain  in  the  extremities  nor  along  the  spine,  or 
in  the  head  and  pressure  at  no  time  caused  any  pain.  There  was 
no  fever,  and  the  intelligence  remained  normal.  Finally,  respira- 
tion became  more  and  more  incomplete,  s}Tnptoms  of  asph^-xia 

1  La  Gaz.  hebd.  de  m6d.  et  de  chir.,  1S59. 


90  THE  SYNONYMS  AND  CLASSIFICATION 

became  more  and  more  general  and  the  patient  died  eight  days 
after  the  onset.  The  autopsy  showed  no  traces  of  any  appreciable 
lesion  of  the  nervous  system;  only  a  pulmonary  involvement  or 
pneumonia  of  recent  date." 

It  is  not  definitely  clear  at  this  time  what  the  disease  was  that 
killed  Landry's  patient,  nor  is  it  always  clear  at  the  present  date 
what  the  nature  of  an  ascending  paralysis  is.  Since  I^andry's  time 
there  has  been  a  disposition  on  the  part  of  physicians  to  call  all 
rapidly  fatal  ascending  or  descending  paralyses  Landry's  paralysis 
without  reference  to  the  disease  which  produced  the  lesion  and 
even  some  of  the  cases  which  recovered  have  been  given  this  name. 
An  acute  ascending  paralysis  may  be  poliomyelitis,  it  may  be  a 
toxic  ascending  myelitis  due  to  bacterial  or  other  poisons,  or  it 
may  be  a  toxic  polyneuritis.  The  last-named  cases  are  apt  to 
recover.  The  ascending  myelitis  and  the  poliomyelitis  of  the  ascend- 
ing type  are  usually  fatal.  There  is  a  growing  feeling  among  phy- 
sicians that  most  of  the  cases  of  the  so-called  Landry's  paralysis 
are  really  poliomyelitis,  and  this  is  no  doubt  true,  although  it  is 
possible  there  may  be  other  diseases  which  cause  the  same  picture. 
There  can,  however,  be  no  doubt  that  the  cases  of  ascending  paraly- 
sis, as  ordinarily  met  with,  are  true  poliomyelitis,  and  this  has 
been  verified  by  studies  of  many  observers.  It  is,  unfortunately, 
a  rather  common  form  of  the  disease.  It  forms  a  characteristic 
group  clinically,  but  should  be  grouped  as  of  the  bulbospinal  type. 
There  is  otherwise  no  reason  to  separate  it.  In  the  cases  which 
have  been  described  as  Landry's  paralysis,  apart  from  those  in  which 
the  diagnosis  of  poliomyelitis  was  certain,  there  has  been  an  ascend- 
ing, seldom  a  descending,  paralysis  running,  as  a  rule,  a  rather  rapid 
course,  generally  not  much  fever,  and  this  has  been  preceded  by 
pain,  tingling,  numbness,  a  sense  of  fatigue,  and  heaviness  in  the 
arms  and  legs.  The  paralysis  either  continues  to  progress  without 
intermission  or  it  may  develop  step  by  step  in  progressive  stages 
and  corresponding  roughly  to  the  spinal  innervation.  When  it 
begins  above  there  is  usually  some  paralysis  of  the  cranial  nerves 
and  the  patient  may  die  of  failure  of  respiration  before  the  legs 
become  paralyzed.  The  paralysis  is  of  a  flaccid  type,  with  no 
changes  in  electric  reaction  except  slight  alteration  in  the  reaction 
to  the  faradic  current.  The  mind  generally  remains  clear,  the  rectal 
and  vesical  sphincters  are  normal,  but  there  may  be  incontinence 
of  urine  from  an  overdistended  bladder,  owing  to  the  paralysis  of 
the  abdominal  muscles.  .  This  picture  is  certainly  strikingly  like 


CLASSIFICATION  91 

that  seen  in  tlie  cases  of  ascending  or  (lescencling  poliomyelitis. 
The  onset  in  these  cases  is  as  in  the  others.  In  many  instances, 
after  the  paralysis  has  developed,  it  spreads  upward  or  downward 
progressively  without  intermission.  In  other  cases  there  is  a  period 
of  onset,  and  then  a  certain  amount  of  paralysis  and  then  a  cessa- 
tion of  the  disease  for  a  matter  of  hours  or  even  days,  when  it  starts 
up  again.  The  patient  may  be  perfectly  conscious  and  may  remain 
so  until  he  dies.  Some  of  the  cases  remain  stuporous  tlu"oughout 
the  course  of  the  disease,  but,  as  a  general  rule,  this  is  not  the  case. 
In  many,  the  mind  seems  to  be  exceedingly  alert  in  striking  contrast 
to  the  terrible  paralysis.  ^Yhen  the  paralysis  starts  to  spread  after 
it  has  stopped,  the  first  thing  that  may  be  noted  is  that  the  breath- 
ing is  more  rapid  than  it  has  been,  that  there  is  hoarseness  and 
loss  of  voice  and  some  difficulty  in  swallowing.  From  then  on  there 
is  usually  a  rapid  development,  one  muscle  after  the  other  of  the 
legs,  trunk,  and  arms  being  aft'ected;  but  the  chief  s^inptoms  seem 
to  come  from  the  involvement  of  the  respiratory  centers.  There 
may  be  paralysis  of  the  intercostals,  or  there  may  be  paralysis  of 
the  diaphragm.  It  is  perfectly  possible  to  have  either  one  and  \vA\e 
the  patient  recover  entirely,  sometimes  with  a  paralysis  of  either 
group.  The  paralysis  of  the  respiratory  muscles  causes  a  rapid, 
labored  breathing.  This  may  be  more  or  less  regular,  and  is  apt 
to  become  irregular,  and  there  may  be  Cheyne-Stokes  breathing. 
The  accessory  muscles  of  respiration  are  brought  into  play,  the 
nose  is  dilated,  and  the  picture  of  respiratory  distress  very  vivid. 
The  head  is  thrown  back  and  the  jaw  dropped  down  and  forward, 
and  the  expression  exceedingly  anxious  and  any  attempt  at  manip- 
ulation or  interference  of  the  child  resented  greatly  if  the  child  is 
able  to  make  any  expression  at  all.  Throughout  this  time  the 
lungs  may  be  clear,  and  they  remain  so  until  death,  or  there  may 
be  the  development  of  a  pulmonary  edema.  In  a  certain  number 
of  cases,  particularly  in  those  in  which  there  is  paralysis  of  the 
diaphragm,  bronchopneumonia  develops  and  may  apparently  be 
the  cause  of  death.  The  heart  is  also  affected,  the  rate  is  usually 
increased,  and  there  are  almost  always  marked  changes  in  the 
rhythm  and  the  rate,  and  these  change  frequently.  These  cases 
are  nearly  always  fatal,  although  occasionally  some  remarkable 
recoveries  occur.  In  most  infectious  diseases  death  is  the  result  of 
a  toxemia.  In  these  cases  of  poliomyelitis,  death  seems  to  be  due 
to  a  failure  of  respiration  or  the  bronchopnemnonia,  most  usually 
the  former.    The  patient  may  be  kept  alive  for  many  hours  after 


92  TBE  SYNONYMS  AND  CLASSIFICATION 

there  has  been  more  or  less  complete  paralysis  of  respiration  by 
the  use  of  artificial  respiration,  particularly  when  combined  with 
oxygen.  Landolt  has  kept  a  patient  alive  for  seventy-two  hours, 
but  the  patient  eventually  died.  This  is  the  fate  of  practically  all 
cases  in  which  artificial  respiration  has  been  done,  but  there  may 
be  cases  in  which  during  artificial  respiration  the  disease  may  cease 
to  extend  and  recovery  take  place.  (The  reader  is  referred  to  the 
remarks  on  Paralysis  of  the  Diaphragm  and  Thoracic  Muscles  and 
to  the  section  on  Diagnosis.) 


CHAPTER  VII. 
PARALYSIS. 

The  Onset  of  Paralysis. — This  is  a  matter  of  considerable  inter- 
est. In  some  instances  the  paralysis  is  the  first  thing  noted  and 
this  led  West  to  speak  of  it  as  "morning  paralysis,"  because  children 
are  found  paralyzed  in  the  morning  after  having  been  put  to  bed 
perfectly  well.  The  paralysis  is  most  apt  to  come  on  during  the 
first  four  days  of  the  disease  and  approximately  an  equal  number 
being  affected  on  each  one  of  the  days.  The  percentage  for  each 
day  varies  somewhat  in  different  epidemics,  but  is  usually  between 
15  and  20  per  cent,  of  the  total  number  of  cases  observed.  After 
four  days  have  elapsed  the  paralysis  is  less  frequent  and  the  num- 
ber of  cases  gets  successively  less  until  after  eight  days  have  passed, 
when  a  very  few  cases  may  be  observed.  After  fifteen  days  have 
passed  the  danger  of  paralysis  is  certainly  very  slight  and  cases 
reported  where  the  interval  is  longer  would  certainly  come  under 
the  class  the  history  of  which  was  to  be  regarded  as  doubtful.  As 
a  matter  of  fact,  one  feels  reasonably  safe  after  eight  days  have 
elapsed. 

On  examining  the  child  the  appearance  is  often  striking.  If  there 
is  meningeal  irritation  the  child  lies  on  its  side  with  the  head  thrown 
back,  resents  being  disturbed  and  is  liable  to  cry  when  anyone 
approaches  it.  The  child  usually  has  a  drowsy,  wilted  look,  but 
sometimes  the  expression  is  one  of  anxiety  or  fright.  If  there  is 
no  meningeal  irritation  the  child  generally  lies  on  its  back,  has  a 
characteristic  curious,  wilted,  tired  expression,  the  head  generally 
to  one  side  or  the  other,  and  the  legs  drawn  up  and  thrown  out  in 
a  sort  of  frog-like  attitude.  The  child  is  usually  drowsy  and  gener- 
ally objects  to  manipulation  of  any  kind. 

The  Diagnosis  of  Paralysis. — In  some  the  paralysis  is  apparent. 
In  others  it  can  only  be  made  out  with  a  very  careful  examination. 
In  adults  and  older  children  the  diagnosis  is  usually  not  attended 
with  any  particular  difficulty,  but  in  the  young  it  may  be  a  very 
perplexing  problem  to  determine  whether  there  is  any  actual  par- 
alysis*or  not. 


94  PARALYSIS 

Appearance  of  Paralysis  in  Days  and  Weeks  after  Onset 
OF  Fever,    Massachusetts  Epidemic  of  1907-10 

Cases.  Per  cent. 

Preceding  attack '   .       2  0.33 

Same  day 95  16.12 

One  day '     .      .     93  15.78 

Two  days 103  17.49 

Three  days 98  16.63 

Four  days 58  9 .  84 

Five  days 22  3.73 

Six  days 51  8.65 

Seven  days 18  3.05 

Eight  days 6  1.01 

Nine  days 2  0.33 

Ten  days 4  0 .  67 

Eleven  days 3  0 .  509 

Twelve  days 5  0.84 

Thirteen  days 1  0.169 

Fourteen  days .       4  0 .  67 

Not  known  (fatal) 1  0.169 

Two  to  three  weeks 6  1.01 

Three  to  four  weeks 1  0 .  169 

Four  to  five  weeks 1  0.169 

Eight  v/eeks 1  0 .  169 

Two  days  previous 1  0.169 

Not  stated 13  2.207 

589 

Appearance   of  Paralysis  in  Days  and  Weeks  after  Onset 
OF  Fever.    Massachusetts  Epidemic  of  1910. 


Same  day 20 

One  day 31 

Two  days 40 

Three  days 34 

Four  days 15 

Five  days ■.      .  11 

Six  days 11 

Seven  days 14 

Eight  days 4 

Nine  days 2 

Ten  days 2 

Eleven  days 2 

Twelve  days 4 

Thirteen  days 1 

Fourteen  days 1 

Two  to  three  weeks 5 

T'hree  to  four  weeks        1 

Four  to  five  weeks 1 

Eight  weeks 1 

200 

It  is  a  good  plan  to  watch  the  child  very  carefully  for  some 
minutes  without  disturbing  it,  and  then  if  it  is  old  enough  ask 


DIAGNOSIS  OF  PARALYSIS 


95 


it   to  move   its   various   extremities,  and   if   it   is    not,  to  induce 
movement  by  gentle  manipulation.     If  this  does  not   succeed  it 


Fig.  22. — Testing  the  Babinski  reflex.     (Musser.) 


Fig.  23.— Testing  the  knee-jerk.     (Musser.) 

may  be  necessary  to  test  motion  by  pinching  or  sticking  with  a 
pin.  If  there  is  p^in  it  is  very  hard  to  tell  whether  the  lack  of  motion 
is  due  to  the  child's  not  wanting  to  move  or  to  a  real  loss  of  power. 


96  PARALYSIS 

Sometimes  the  paralysis  can  be  noted  by  suddenly  stretching  the 
muscle,  as  suddenly  straightening  out  a  flexed  forearm,  and  nor- 
mally the  resistance  of  the  biceps  is  quite  apparent,  whereas  if  it 
is  paralyzed,  the  resistance  is  wanting.  In  young  infants  it  is  often 
advisable  to  hold  the  child  in  the  hand  in  different  positions,  when 
the  paralysis  may  often  be  easily  detected  by  the  way  the  limb 
drops.    It  is  interesting  to  note  how  the  child  will  turn  instinctively 


Fig.  24. — Paralysis  of  left  arm  and  left  leg. 

to  get  the  aid  of  the  force  of  gravity  in  making  the  movement  of  a 
paralyzed  extremity.  Sometimes  when  no  paralysis  can  be  made 
out  the  child  cannot  stand,  probably  owing  to  weakness  of  the 
gluteal  muscles,  the  quadriceps  or  the  back  muscles. 

The  Paralytic  Cases. — As  we  have  seen,  paralysis  is  not  a  neces- 
sary part  of  the  poliomyelitis  infection.  It  is,  however,  the  most 
dominant  symptom  in  a  large  proportion  of  cases,  and  the  persis- 
tence of  the  paralysis  with  the  consequent  loss  of  power  and  func- 


SPINAL  FORM  97 

tion  is  what  most  fixes  the  attention  of  both  the  physician  and  of 
the  layman.  A  disease  may  be  feared  on  account  of  its  causing  death, 
but  a  disease  which  permits  the  patient  to  Hve  in  an  enfeebled 
condition  is  even  more  dreaded  and  its  occurrence  in  a  community 
makes  a  much  deeper  impression.  The  comparative  callousness 
with  which  the  population  watches  the  annual  destruction  of  infants 
by  the  diarrheal  diseases  is  too  well  known  to  be  commented  upon, 
while  50  cases  of  poliomyelitis  will  throw  a  community  of  500,000 
into  a  panicky  state  of  mind. 

The  most  striking  thing  about  the  paralysis  is  the  fact  that  it  is 
so  thoroughly  unsymmetrical;  almost  any  combination  of  the 
paralyzed  muscles  that  can  be  imagined  has  been  described.  In  a 
very  large  number  of  instances  the  paralysis  is  limited  to  a  muscle 
or  a  muscle  group,  or,  if  at  the  beginning  the  whole  extremity  has 
been  affected,  it  almost  invariably  happens  that  the  residual  paraly 
sis  is  limited  to  a  muscle  or  muscle  group.  In  a  large  number  of 
cases  there  may  be  weakness  of  the  muscles  or  of  muscle  groups 
without  any  actual  paralysis,  or  there  may  be  a  partial  loss  of  power 
due  to  the  fact  that  the  muscle  is  innervated  from  several  nerve  roots. 

The  Spinal  Form. — The  wisdom  of  the  complicated  cervical, 
brachial,  and  other  plexuses  becomes  very  apparent  when  one  studies 
the  paralytic  conditions  of  poliomyelitis.  Partial  paralysis  is  par- 
ticularly well  noted  in  the  deltoid,  where  the  anterior  and  posterior 
half  may  work  independently.  It  also  has  been  demonstrated 
in  the  pectoralis  major  and  in  other  muscles.  The  reason  for  the 
predominance  of  partial  over  total  paralysis  seems  to  lie  in  the 
grouping  of  the  cells  in  the  anterior  horns  of  the  cord.  These  cells 
lie  in  longitudinal  groups,  which  are  largest  in  the  cervical  and 
lumbar  regions.  Each  anterior  root  contains  fibers  from  several 
groups  of  cells,  and  these  fibers  are  distributed  along  several  nerve 
trunks.  Lesions  in  the  anterior  nerve  roots  or  in  parts  of  the  groups 
of  nerve  cells,  unless  very  extensive,  will  merely  weaken,  but  not 
completely  paralyze  the  muscles.  The  toxin  of  poliomyelitis  very 
probably  reaches  the  cord  through  the  circulation,  chiefly  from  the 
branches  of  the  anterior  spinal  artery,  which  enter  horizontally  at 
difl'erent  levels.  The  planes  of  destruction  are  likely  to  be  trans- 
verse, while  the  lines  of  nerve  center  association  are  longitudinal, 
so  that  a  muscle  which  derives  its  nerve  supply  from  a  group  of 
nerve  cells  occupying  several  segments  would  have  some  power 
remaining,  as  a  transverse  lesion  might  easily  leave  some  of  the 
centers  intact. 
7 


Distribution  of  Paralysis  in  868  Cases  According  to 

WiCKMAN.  Cases. 

One  or  both  legs 353 

One  or  both  arms 75 

Combination  of  arms  and  legs 152 

Combination  of  legs  and  trunk  muscles •.      .      .      .  85 

C^ombination  of  arms  and  trunk  muscles 10 

Trunk  muscles  alone 9 

Paralysis  of  "the  whole  body" 23 

Ascending  paralysis 32 

Descending  paralysis 13 

Combination  of  spinal  and  cranial  nerves 34 

Cranial  nerves  alone 22 

Localization  of  paralyses  not  given 60 

Distribution  of  Early  Paralysis.     Massachusetts  Epidemic 

OF    1910.  Cases. 

One  leg  only 145 

Both  legs  only 146 

One  arm  only 44 

Both  arms  only 12 

One  arm  and  leg,  same  side 50 

One  arm  and  leg,  opposite  sides 18 

Both  legs  and  one  arm 32 

Both  arms  and  one  leg 8 

Both  arms  and  both  legs 51 

Ataxia  (transitory) 7 

Back .  79 

Abdomen 38 

Neck 13 

Respiration 39 

Deglutition 12 

Intercostal 1 

Face 7 

Right  face 31 

Left  face 24 

Strabismus 2 

Not  stated 32 

Distribution  of  Paralysis  (1907-10).    Report  of  the 
Massachusetts  Epidemic  of  1910. 

Cases.  Per  cent. 

One  leg  only 324  27.97 

Both  legs  only 272  23.48 

Back 154  13.29 

Both  arms  and  both  legs 129  11.13 

One  arm  and  leg,  same  side 110  9.49 

One  arm  only 84  7 .  25 

Both  legs  and  one  arm 75  6.47 

Face 74  6.38 

Abdomen 67  5.78 

One  arm  and  leg,  opposite  sides 33  2 .  84 

Respiration 31  2.67 

Both  arms  only 23  1.98 

Neck .     11  0.94 

Both  arms  and  one  leg 10  0 .  86 

Deglutition 7  0.604 

Neck  and  back 6  0.51 

Ataxia  (transitory) 5  0.43 

General 3  0.25 

Intercostal 1  0.086 

Both  arms,  back,  chest  and  throat 1  0.086 

Total 1420 


SPINAL  FORM  99 

A  glance  at  the   preceeding  tables   will  show  the  general  dis- 
tribution of  the  paralyses. 

There  are  variations  in  different  epidemics;  thus,  while  the  legs 
are  most  frequently  affected  there  have  been  instances  in  which 
paralysis  of  the  arms  predominated,  although  these  are  probably 
very  rare.  The  legs  are  innervated  from  the  first  lumbar  through 
the  second  sacral  segments  of  the  cord,  and  this  particular  part 
of  the  cord  probably  has  the  largest  blood  supply.  Any  muscle  or 
any  group  of  muscles  may  be  affected,  but  in  the  upper  part  of  the 
leg  the  quadriceps  femoris  is  most  frequently  paralyzed,  while  in 
the  lower  leg  the  anterior  group  of  perineals,  the  flexors  of  the 
foot,  and  the  extensors  of  the  toes  are  most  frequently  involved. 
The  paralysis  may  involve  either  one  or  both  legs  together,  in 
many  instances  with  paralysis  in  other  parts  of  the  body.  It  is  apt 
to  be  rather  extensive  at  first,  but  almost  invariably  there  is  more 
or  less  recovery.  The  flexors  of  the  toes  are  often  not  affected,  or 
if  they  are,  are  the  first  to  recover.  This,  together  with  the  force 
of  gravity  and  the  pull  of  other  muscles,  results  in  the  very  common 
toe-  and  foot- drop  of  particular  interest,  both  on  account  of  its 
frequency  and  on  account  of  difficulty  in  maintaining  a  correct 
position  to  prevent  overstretching  of  the  weakened  muscles  and 
deformity.  In  the  study  made  in  Vermont  by  Lovett,  the  paraly- 
sis was  found,  on  the  whole,  more  frequently  in  the  hip  and  dimin- 
ished in  frequency  toward  the  foot — that  is,  the  individual  muscles 
in  the  upper  segment  were  more  often  affected  than  in  the  lower, 
but  the  paralysis  was,  on  the  whole,  lightest  in  the  hip,  next  lightest 
in  the  thigh  and  most  severe  in  the  lower  leg — that  is,  the  propor- 
tion of  total  to  partial  paralysis  increases  as  one  went  away  from 
the  hip  toward  the  foot.  The  legs  were  affected  nearly  equally, 
the  figures  being  slightly  higher  for  the  right,  but  not  essentially 
different.  This  is  in  marked  contrast  to  the  predominance  of  the 
paralysis  of  the  left  arm.  In  the  experience  of  other  observers  the 
left  arm  has  not  always  predominated.  The  arms  are  innervated 
from  the  fifth  cervical  through  the  first  thoracic  segment.  As  a 
rule,  only  one  arm  is  affected,  and  in  most  instances  in  which  the 
arm  is  paralyzed  there  is  also  paralysis  of  the  legs.  The  paralysis 
of  one  or  of  both  arms  without  other  involvement  may  occur,  or 
there  may  be  the  added  paralysis  of  the  face  or  of  the  diaphragm. 
Paralysis  of  both  arms  alone  without  other  involvement  is  appar- 
ently of  very  rare  occurrence.  The  paralysis  is  most  frequent  at 
the  shoulder  and  diminishes  in  frequency  from  the  shoulder  to  the 


100 


PARALYSIS 


hand.  The  deltoid  and  shoulder  group  are  most  often  affected 
and  the  atrophy  of  the  deltoid  in  some  cases  may  be  extraordi- 
narily rapid  and  complete;  but  even  when  this  happens,  either 
complete  or  more  or  less  complete  recovery  may,  at  times,  take 
place.  The  flexors  of  the  fingers  are  less  frequently  affected,  or  if 
paralyzed,  recover  more  quickly  than  the  extensors.  The  recovery 
of  the  distal  muscles  takes  place  more  quickly  and  more  com- 
pletely than  the  muscles  nearer  the  trunk.    The  complete  perma- 


FiG.  25. — Paralysis  of  the  left  deltoid  muscle,  showing  the  elevation  of  the  shoulder 
when  the  patient  attempts  to  abduct  the  arm.     (Whitman.) 

nent  paralysis  of  an  arm  is  rare,  but  a  more  or  less  complete  par- 
alysis of  a  shoulder  group  is  not  an  uncommon  result.  Lovett  has 
advanced  an  interesting  theory. '^  He  believes  that  the  frequency 
of  the  paralysis  corresponds  to  the  functions  of  the  muscles  involved. 
The  right  arm  is  used  much  more  actively  than  the  left,  and  also 
for  more  complicated  movements.    The  legs  are  used  equally.    It 


1  Bull.  Med.  and  Chirurg.  Faculty  of  Maryland,  June,  1915,  p.  169. 


SPINAL  FORM  101 

seems  that  the  muscles  used  actively,  continuously,  and  in  a  more 
complicated  way  are  more  apt  to  escape  than  those  used  less,  or 
for  simpler  or  less  complicated  work.  This  difference  may  be  due 
to  the  difference  in  blood  supply,  which  one  would  suppose  to  be 
greater  and  more  free  around  the  centers  governing  the  greatest 


Fig.  26. — Illustrating  the  improvement  in  the  range  of  abduction  obtained  by 
transplantation  of  the  trapezius  muscle.  The  line  of  the  incision  is  shown.  (Whit- 
man.) 

activity.  If  this  idea  is  correct,  one  would  expect  to  find  a  higher 
proportion  of  difference  in  older  individuals.  In  24  patients,  five 
years  old  and  younger,  there  were  twelve  left  arms  and  twelve 
right  arms  paralyzed,  a  ratio  of  1  to  1.  In  27  cases  over  five  years 
of  age  there  were  20  cases  of  left- arm  paralysis  and  7  of  right,  a  ratio 
of  3  to  1.      This  also  agrees  with  the  distribution  of  the  paralysis 


102 


PARALYSIS 


in  arms  and  legs,  which  is  most  frequent  near  the  trunk,  the  hip 
and  shoulder  muscles  performing  less  continuous  and  simpler  tasks 
than  those  of  the  lower  leg  or  forearm,  or  of  the  hand  and  foot. 

It  has  been  shown  that  the  muscles  of  the  upper  extremities  are 
more  severely  affected  nearest  the  trunk  and  less  severely  lower 
down,  whereas  in  the  leg  this  relation  is  reversed,  and  the  largest 
proportion  of  severe  paralysis  is  seen  in  the  lower  leg  and  foot. 
This  is  probably  due  to  the  weight  coming  on  each  muscle  in  the 
activities  of  the  upright  position.    In  the  arm  the  deltoid,  triceps, 


Fig.  27. — Extreme  atrophy  of  the  shoulder,  arm  and  forearm  in  an  adult  who 
suffered  from  an  attack  of  infantile  paralysis  at  the  age  uf  three.     (Starr.) 


and  biceps  are  all  used  to  hold  up  the  arm  against  the  shoulder- 
joint,  so  that  the  upper  muscles  have  a  greater  amount  of  weight 
to  take  care  of  than  those  lower  down.  This,  of  course,  is  reversed 
in  the  legs,  as  the  lower  muscles  have  more  weight  to  carry  than 
the  upper  ones.  Whether  this  explanation  is  correct  or  not  is  a 
question,  but  there  is  no  question  about  the  correlation  of  the 
facts.  The  severity  of  the  distribution  cannot  be  connected  with 
the  size  of  muscles  or  function  of  a  peculiar  sort,  nor  can  it  be 
connected  with  local  changes  in  the  circulation.    It  does  not  seem 


PARALYSIS  OF   THE  BACK  MUSCLES  103 

to  be  connected  with  spinal  localization.  The  distribution  as 
regards  the  severity  is  in  proportion  to  the  weight  to  be  met  by  the 
different  muscles,  and  may  be  due  to  the  retardation  of  the  recov- 
ery of  the  muscles  that  work  against  the  greatest  weight.  This 
has  a  bearing  upon  the  treatment,  and  may  account  for  the  ill 
effects  on  muscular  recovery  from  overuse. 

Lovett's  conclusions  are  only  tentative,  and  will  be  subject  to 
further  studies;  but  he  seems  to  have  definitely  proved  that  there 
is  another  factor  besides  the  plain  anatomical  distribution  of  the 
lesion  in  the  cord,  which  determines  something  of  the  extent  and 
severity  of  the  residual  paralysis. 

Paralysis  of  the  Neck. — This  may  occur  alone  or  in  connection 
with  paralysis  of  the  muscles  of  the  back.  Weakness  of  the  anterior 
muscles  of  the  neck,  allowing  the  head  to  fall  back,  is  very  com- 
mon and  a  very  useful  aid  in  diagnosis.  If  a  patient  is  lifted  by 
placing  the  hands  under  the  shoulders  the  head  generally  falls 
back.  If  the  patient  is  told  to  raise  his  head,  if  he  is  able  to  do  it, 
he  will  generally  hold  it  raised  for  a  moment  or  two  and  then  it 
falls  back  again  and  he  is  not  able  to  bring  it  up  any  more.  This 
sign,  we  believe,  was  first  described  by  Peabody,  Draper  and 
Dochez,  and  is  usually  referred  to  as  the  "head  sign."  The  child, 
in  many  instances,  assumes  a  position  with  the  head  thrown  back 
when  the  muscles  are  not  paralyzed,  merely  because  he  finds  it  a 
comfortable  position.  The  head  falls  backward,  to  the  side,  or  to 
the  front,  depending  upon  which  muscles  are  involved,  or  if  more 
or  less  all  of  the  muscles  are  involved  the  head  falls  according  to 
the  position  in  which  the  child  is  placed.  Permanent  paralysis  of 
the  neck  muscles  is  usually  seen  only  in  very  extensive  paralysis, 
but  we  have  seen  one  instance  in  which  the  neck  muscles  seemed  to 
be  the  only  ones  remaining  paralyzed. 

Paralysis  of  the  Back  Muscles. — It  is  very  probable,  as  Miiller 
has  pointed  out,  that  involvement  of  some  of  the  back  muscles  is 
of  \-ery  common  occurrence,  but  it  is  very  difficult  to  make  out 
during  the  acute  stage  because  the  child  may  be  too  ill  to  sit  up  or 
stand  and  a  loss  of  power  cannot  be  told  from  the  general  weak- 
ness which  goes  with  any  severe  illness.  In  most  instances  in  which 
the  back  muscles  are  affected,  so  that  it  is  easily  made  out  there  is 
parah'sis  of  other  parts  of  the  body,  usually  of  a  very  severe  nature, 
but  in  some  instances  the  muscles  of  the  back  may  be  affected  alone. 
It  may  be  bilateral  or  unilateral.  Where  it  is  bilateral  the  body 
topples  sidewise,  forward  or  back,  and  the  patient  is  unable  to  sit 


104 


PARALYSIS 


up.  Where  it  is  unilateral  the  patient  sometimes  is  able  to  sit  up, 
but  there  is  a  marked  scoliosis  with  the  convexity  to  the  paralyzed 
side.  In  most  instances  the  paralysis  of  the  back  muscles  clears  up. 
but  there  are  cases  in  which  the  condition  persists,  and  is  either 
attended  with  a  scoliosis  or  the  patient  may  be  so  severely  affected 
as  not  to  be  able  to  sit  up  at  all. 

Paralysis  of  the  Diaphragm  .^ — The  diaphragm  is  supplied  by  the 
phrenic  nerve,  which  comes  from  the  third,  fourth,  and  fifth  cervi- 


FiG.  28. — Paralysis  of  thoracic 
muscle. 


Fig.  29. — Paralysis  of  thoracic  muscle. 


cal  segments.  This  part  of  the  cord  seems  to  be  involved,  but 
very  infrequently,  except  in  cases  which  have  a  fatal  outcome, 
although  it  may  occasionally  happen  that  the  diaphragm  may  be 
paralyzed  and  the  patient  recover,  and  the  paralysis  of  the  dia- 
phragm itself  may  clear  up  entirely,  even  if  it  has  been  affected  as 
long  as  one  or  two  weeks.  It  is  usually  the  last  muscle  to  be  involved 
in  the  fatal  cases,  and  comes  on  after  the  intercostals,  in  which  case 
death  follows  soon  after.  This  is  most  likely  to  happen  in  the 
very  extensive  cases,  or  in  those  of  an  ascending  or  descending  type. 


PARALYSIS  OF   THE  DIAPHRAGM 


105 


Fig.  30. — Paralysis  of  thoracic 
muscle. 


Fig.  31. — Paralysis  of  thoracic  muscle. 


Fig.  32. — Paralysis  of  thoracic  muscle. 


106  PARALYSIS 

The  appearance  of  the  child  with  a  paralysis  of  the  diaphragm 
is  quite  characteristic.  The  respiration  is  entirely  of  a  thoracic 
character,  and  usually  the  accessory  muscles  of  respiration  are 
brought  into  action.  If  the  patient  is  conscious,  and  they  usually 
are,  the  expression  is  extremely  anxious,  and  any  movement  toward 
the  child  to  tend  to  disturb  it  is  resisted  as  far  as  it  lies  in  the  power 
of  the  child  to  express  fear.  In  normal  respiration,  with  each  inspi- 
ration, the  abdomen  is  pushed  forward,  whereas  when  the  diaphragm 
is  paralyzed  there  is  a  retraction  of  the  abdomen  with  each  inspira- 
tion. Firm  pressure  on  the  thorax  causes  a  very  rapid,  labored 
respiration,  without  producing  any  diaphragmatic  breathing. 
Peabody,  Draper  and  Dochez  have  called  attention  to  the  fact 
that  in  sobbing  children  the  respiration  may  be  entirely  of  a  thoracic 
nature,  and  might  lead  to  a  mistaken  diagnosis.  This  will  not 
occur,  however,  if  the  child  is  allowed  to  quiet  down  before  the 
decision  is  made. 

Paralysis  of  the  Intercostals. — The  thoracic  part  of  the  cord  is  also 
rarely  involved  if  one  excepts  the  fatal  cases.  It  is  most  often  seen 
in  cases  with  very  extensive  paralysis  and  those  of  the  ascending 
or  descending  type.  The  patients  with  intercostal  paralysis  usually 
die,  but  they  may  recover  entirely  or  they  may  recover  and  have 
a  permanent  paralysis  of  the  intercostal  muscles.  The  paralysis 
may  be  partial  or  complete.  Very  curious  acute  clinical  pictures 
are  produced  by  paralysis  of  one-half  of  the  chest.  The  cases"  in 
which  there  is  only  a  partial  involvement  may  be  extremely  difficult 
to  detect.  In  the  complete  cases  the  picture  is  very  striking,  as 
will  be  seen  in  the  accompanying  figures  of  a  case  that  occurred 
at  the  Children's  Hospital  School.  The  respiration  is  diaphragmatic 
in  character,  and  the  thorax  remains  more  or  less  fixed  and  has  a 
downward  movement  on  inspiration  in  place  of  the  normal  upward 
and  forward  movement.  Pressure  on  the  abdomen  causes  labored 
and  difficult  breathing. 

Paralysis  of  the  Abdominal  Muscles. — Paralysis  of  the  abdominal 
muscles  is  not  infrequent.  The  condition  may  be  somewhat  diffi- 
cult to  tell,  particularly  in  very  ill  children,  in  which  there  is  almost 
always  a  distinct  flaccidity  of  the  abdominal  muscles.  It  is  fre- 
quently seen  in  fatal  cases,  and  very  often  one  is  in  doubt  as  to 
whether  there  is  actually  a  paralysis  or  not.  The  rectus  abdominis 
most  usually  escapes  involvement,  but  most  usually  all  or  part  of 
the  external  and  internal  part  of  the  trans versalis  may  be  affected. 
In  many  instances  the  paralysis  is  transient  and  disappears  after  a 


SPHINCTERS 


107 


week  or  two.  When  the  paralysis  is  partial  there  is  bulging  of  the 
abdominal  wall  at  the  affectefl  part,  and  this  greatly  increases  when 
the  child  cries  or  coughs  or  attempts  to  sit  up.  When  the  paraly- 
sis is  more  or  less  extensive  it  produces  a  laxness  of  the  abdominal 
wall  which  may  be  very  marked  in  case  there  is  much  gas  in  the 
intestines,  and  if  it  persists  the  patient  stands  and  walks  in  a 
sway-back  manner,  with  the  hips  flexed,  the  lumbar  spine  bent 
backward,  and  the  abdomen  pushed  forward  in  a  prominent  way. 


Fig.  33. — Abdominal  muscle  palsy — poliomyelitis.     (Frauenlhal.) 


If  it  is  one-sided  the  patient  may  drop  the  pelvis  to  the  weak  side 
and  the  position  assumed  may  suggest  that  of  a  patient  with 
congenital  dislocation  of  the  hip. 

The  Sphincters.— The  sphincters  of  the  bladder  and  rectum  are 
seldom  affected.  Vesical  paralysis  does  occasionally  occur,  but  is 
probably  but  very  rarely  permanent,  and  a  permanent  paralysis 
of  the  rectal  sphincter  is  probably  even  less  frequent.  In  the 
patients  who  are  very  ill  and  in  those  that  are  extensively  paralyzed 


108  PARALYSIS 

there  may  be  little  or  no  control  of  the  bowel,  and  the  patients 
may  be  difficult  to  nurse  for  this  reason;  but  if  the  patient  recovers 
control  of  the  sphincter  it  is  almost  invariably  regained. 

Involvement  of  the  Ciliospinal  Ganglia. — Peabody,  Draper  and 
Dochez  report  one  case  of  extraordinary  interest  which  was  appar- 
ently due  to  involvement  of  the  ciliospinal  ganglia,  which  is  situated 
in  the  eighth  cervical  and  first  thoracic  segment.  The  patient  had 
a  flaccid  left  arm,  and  there  was  a  failure  of  the  left  pupil  to  dilate, 
together  with  narrowing  of  the  left  eyelid.  In  addition  to  this  there 
was  hemicranial  sweating  and  a  hemicranial  vasomotor  disturbance. 

The  Cranial  Nerves. —  The  First  Nerve. — The  first,  or  olfactory, 
nerve  either  escapes  or  the  affections  of  this  nerve  are  not  discov- 
ered, as  in  a  very  extensive  review  of  the  literature  we  have  not 
seen  any  mention  either  of  cases  of  involvement  of  it  or  any  record 
of  tests  being  made  to  ascertain  whether  it  was  affected  or  not. 
So  many  of  the  acute  cases  are  in  very  young  children  that  it  would 
be  impossible  to  make  accurate  observations,  but  a  study  among 
older  children  and  adults  would  certainly  be  most  interesting. 

The  Second  Nerve. — ^The  second,  or  ocular,  nerve  contains  the 
visual  fibers  and  some  to  the  pupil.  In  some  cases  there  is  photo- 
phobia which  may  be  particularly  marked  at  the  onset  or  during 
the  first  few  days.  In  a  few  instances  blindness  has  been  recorded, 
but  it  seems  to  be  a  rare  affection,  and  in  some  cases,  fortunately,  is 
of  short  duration.  There  is  some  difference  of  opinion  regarding 
the  state  of  the  eye-grounds,  and  the  subject  needs  further  study. 
Tedeschi^  observed  an  instance  in  which  there  was  optic  atrophy 
in  an  old  case.  Wickman  reports  optic  neuritis  in  a  recent  case, 
but  Miiller  in  a  study  of  a  considerable  number  of  cases  did  not  find 
any  changes  in  the  eye-grounds,  and  was  of  the  opinion  that  if  optic 
neuritis  was  present  the  case  was  not  to  be  classed  as  a  poliomye- 
litis. This  whole  subject  is  one  on  which  we  cannot  at  the  present 
state  of  our  knowledge  make  any  dogmatic  statements. 

The  Third,  Fourth  and  Sixth  Nerves.- — ^The  third,  fourth,  and  sixth 
nerves  control  the  voluntary  muscles  of  the  eye  and  are  not  infre- 
quently affected.  There  have  been  a  number  of  instances  of  com- 
plete ocular  motor  paralysis,  such  cases  having  been  reported  by 
Wickman,  and  we  had  an  opportunity  during  the  New  York 
epidemic  of  1916  to  see  one  instance.  In  these  cases  the  patient 
is  unable  to  move  the  eyes  in  any  direction,  and  has  to  depend  on 

lAtti  dell'  Acadameia  di  Scienze  mediche  naturali  in  Ferrara,  1904. 


CRANIAL  NERVES  109 

moving  the  head  and  take  a  chance  on  the  eye  coming  in  line  with 
the  object  desired  to  be  looked  at. 

The  third,  or  ocular  motor,  nerve  controls  all  the  muscles  except 
those  supplied  by  the  fourth,  which  supplies  the  superior  oblique, 
and  the  sixth,  which  supplies  the  external  rectus.  It  also  supplies 
the  voluntary  part  of  the  muscles,  raising  the  eyelid,  the  involun- 
tary part  being  supplied  by  the  cervical  sympathetic.  There  may 
be  either  complete  or  partial  paralysis  of  the  third  nerve.  Ptosis 
may  be  present  and,  in  fact,  may  be  the  only  sign  of  eye  involve- 
ment. There  is  also  overaction  of  the  frontalis,  so  that  the  eyebrow 
is  higher  on  the  affected  side  than  on  the  good  side.  There  is  an 
external  strabismus  caused  by  the  sixth  nerve  being  unopposed  and 
an  inability  to  move  the  eye  upward,  directly  downward  or  directly 
inward,  although  the  superior  oblique  can  still  give  a  slight  upward 
and  inward  movement.  The  pupil  is  dilated,  due  to  paralysis  of 
the  sphincter,  and  it  does  not  react  either  to  light  or  accommoda- 
tion. Involvement  of  the  third  nerve  is  not  the  commonest  of  the 
ocular  palsies,  however. 

The  fourth,  or  superior  oblique,  nerve  may  occasionally  be 
affected,  but  if  it  is,  it  is  almost  always  overlooked,  inasmuch  as 
the  movements  of  the  eye  are  but  slightly  affected.  The  patient, 
however,  has  a  characteristic  diplopia  which  comes  on  when  he 
looks  downward  and  outward.  The  false  image  is  lower  than  the 
true,  and  the  upper  end  is  tilted  toward  the  other.  If  the  patient 
is  up  and  about  and  looking  downward,  as  in  walking  down  stairs, 
causes  dizziness  and  the  head  is  held  forward  and  toward  the  sound 
side. 

The  sixth,  or  external  rectus,  nerve  is  the  most  commonly  affected 
in  poliomyelitis.  This  is  easily  detected,  inasmuch  as  the  patient 
is  unable  to  turn  the  eye  outward  beyond  the  middle  point,  although 
all  the  other  movements  are  normal.  The  patient  also  has  a  diplopia 
on  looking  outward. 

The  Fifth  Nerve. — The  fifth,  or  trigeminal,  nerve  contains  sen- 
sory and  motor  fibers.  It  is  divided  into  three  parts :  the  first,  the 
ophthalmic  division,  being  sensory  nerves,  but  it  also  contains 
efferent  pupil-dilating  powers  from  the  cervical  sympathetic.  The 
second,  or  superior  maxillary,  is  also  sensory,  whereas  the  third, 
or  inferior  maxillary,  is  both  motor  and  sensory.  When  the  fifth 
nerve  is  totally  paralyzed  there  is  an  anesthesia  on  the  same  side 
of  the  face  and  scalp,  but  not  extending  as  far  as  the  angle  of  the 
jaw,  where  the  skin  is  supplied  from  the  cervical  plexuses.   There  is 


no 


PARALYSIS 


anesthesia  of  the  cornea  and  conjunctiva,  of  the  mucous  membrane 
of  the  corresponding  side  of  the  nose,  mouth,  and  soft  palate,  and 


Fig.  34. — Left  facial  paralysis. 


Fig.  35. — Slight  right  facial  paralysis 
Note  wrinkling  of  nose  on  the  left  side. 


as  far  back  as  the  circumvallate  papillae.    Behind  these  the  tongue 
is  supplied  by  the  glossopharyngeal.    There  is  a  tendency  for  food 


Fig.  36. — Slight  left  facial  paralysis. 


Fig.  37. — Right  facial  paralysis. 


to  collect  on  the  affected  side,  owing  to  the  anesthesia,  even  though 
the  motor  power  of  the  buccinator  muscles  is  unimpaired.     The 


CRANIAL  NERVES 


111 


Fig.  38. — Left  facial  and  hypoglossal 
paralysis. 


Fig.  39. — Right  facial  paralysis. 


Fig.  40. — Left  facial  paralj"sis. 


112  PARALYSIS 

anesthesia  extends  to  the  middle  Hne  and  the  patient  has  a  sensation 
as  if  he  were  drinking  out  of  a  broken  cup.  There  is  impairment 
of  taste  in  the  anterior  two-thirds  of  the  tongue.  Owing  to  the  fifth 
nerve  supplying  sensory  fibers  to  the  facial  muscles  there  is  an 
apparent  or  pseudofacial  paralysis.  The  motor  fibers  supply  the 
masseter,  temporal,  and  both  pterygoid  muscles,  as  well  as  the  tensor 
tjmipani,  masseter,  mylohyoid  and  the  anterior  belly  of  the  digas- 
tric. The  atrophy  of  the  temporal  and  masseter  is  usually  very 
apparent  and  the  zygoma  looks  abnormally  prominent.  There 
may  be  dryness  of  the  eye  on  the  affected  side;  there  may  be  no 
sneezing  from  the  application  of  snuff  to  the  nasal  mucous  membrane 
and  the  sense  of  smell  on  the  affected  side  may  also  be  impaired. 

In  poliomyelitis  the  motor  part  of  the  nerve  is  most  apt  to  be 
affected.  There  has  been  but  little  noted  about  the  sensory 
involvement. 

The  Seventh  Nerve. — The  seventh,  or  facial,  nerve  is  perhaps  the 
most  frequently  affected  of  all.  The  paralysis  of  this  nerve  in 
poliomyelitis  can  very  easily  be  mistaken  for  the  paralysis  due  to 
neuritis  after  it  leaves  the  stylomastoid  foramen,  the  so-called 
Bell's  paralysis,  but  in  poliomyelitis  there  is  very  apt  to  be  an  accom- 
panying sixth  nerve  involvement  in  the  bulbar  lesions  affecting  the 
facial  nerve.  Taste  and  hearing  are  unaffected.  If  the  lesion  is 
within  the  Fallopian  aqueduct  there  is  a  loss  of  taste  in  the  anterior 
two-thirds  of  the  tongue,  and  sometimes  disturbances  of  secretion 
of  saliva  of  the  submaxillary  and  sublingual  glands,  and  there  may 
be  unusual  sensitiveness  to  loud  sounds.  If  these  symptoms  are 
present  it  might  be  regarded  as  a  point  against  the  condition  being 
due  to  poliomyelitis.  Involvement  of  the  facial  nucleus  affects  the 
symmetry  of  the  face  even  at  rest,  and  this  is  very  much  exaggerated 
on  moving  the  facial  muscles.  Asking  the  patient  to  laugh  or  to 
whistle,  or,  in  some  children,  causing  crying,  will  usually  bring  out 
the  loss  of  power  very  plainly.  The  patient  cannot  wrinkle  the 
forehead,  the  eye  is  open  and  cannot  be  shut,  tears  run  over  the 
cheek,  and  the  irregular  involuntary  winking  of  health  is  absent. 
Sometimes  the  eye  is  shut  during  sleep,  or  almost  so,  supposedly 
from  the  relaxation  of  the  levator  palpebrse.  The  tip  of  the  nose 
may  be  drawn  a  little  to  the  sound  side  and  the  mouth  is  also  pulled 
to  the  sound  side,  whereas  on  the  other  side  it  may  droop  and 
saliva  may  run  from  it.  The  labial  consonants  are  pronounced  with 
difficulty,  and  during  chewing  the  food  is  apt  to  collect  between  the 
teeth  and  the  paralyzed  cheek.    In  poliomyelitis  there  is  very  fre- 


CRANIAL   NERVES  113 

qiiently  involvement  of  some  of  the  other  cranial  nerves  as  well, 
especially  the  sixth  or  the  twelfth. 

The  Eighth  Nerve. — There  are  very  few  observations  dealing 
with  the  ear  in  poliomyelitis.  The  changes  one  would  expect  to 
find  would  be  either  deafness,  tinnitus,  or  vertigo.  In  a  few  instances 
in  which  the  ear  was  examined  it  was  either  found  to  be  normal  or 
there  was  slight  injection  of  the  bloodvessels,  particularly  near  the 
insertion  of  the  handle  of  the  hammer.  Special  study  of  the  ear  in 
future  epidemics  will  probably  throw  a  great  deal  of  light  on  the 
subject. 

Ninth  Nerve. — When  the  ninth,  or  glossopharyngeal,  nerve  is 
affected  there  is  difficulty  in  swallowing  and  a  loss  of  taste  and 
common  sensation  on  the  posterior  third  of  the  tongue  on  the 
affected  side  and  also  on  the  soft  palate.  Common  sensation  is 
also  lost  in  the  upper  part  of  the  pharynx.  It  is  quite  probable 
that  the  difficulty  in  swallowing  seen  in  the  cases  that  ultimately 
prove  fatal,  may  be  due  to  involvement  of  the  ninth  nerve. 

The  Tenth  Nerve. — The  tenth,  or  the  vagus  or  pneumogastric, 
nerve  supplies  the  pharynx,  larynx,  esophagus,  heart,  lungs,  stom- 
ach, and  part  of  the  intestines  and  spleen.  It  contains  both  motor 
and  sensory  fibers.  If  one  pneumogastric  is  affected  there  is  paraly- 
sis of  one  side  of  the  palate,  which  can  be  made  out  by  asking  the 
patient  to  say  "Ah"  when  the  palate  is  pulled  up  on  the  sound 
side  and  there  is  a  one-sided  paralysis  of  the  larynx  and  anesthesia  of 
the  larynx  on  the  affected  side.  The  voice  is  apt  to  be  hoarse,  but 
not  entirely  absent.  If  both  nerves  are  affected  there  is  profound 
alteration  of  the  respiration  and  circulation.  The  respiration  is 
slow  and  irregular,  and  the  heart  beats  very  irregularly,  and  there 
is  usually  pronounced  tachycardia.  In  some  instances  there  are 
spells  of  respiratory  distress  and  accompanying  tachycardia,  which 
have  been  described  by  Medin,  Wickman  and  others.  In  some  cases 
there  is  Cheyne-Stokes  breathing. 

The  Eleventh  Nerve. — ^The  eleventh,  or  spinal  accessory,  nerve 
is  entirely  motor  and  supplies  the  sternomastoid  and  part  of  the 
trapezius.  Paralysis  of  the  sternomastoid  shows  itself  in  rotating 
the  head,  when  the  sternomastoid  does  not  stand  out  prominently 
as  it  does  normally.  The  trapezius  paralysis  causes  a  downward 
and  outward  displacement  of  the  scapula,  so  that  the  inner  border 
is  no  longer  parallel  to  the  spine,  and  when  the  patient  presses  the 
shoulder  back  the  scapula  is  unevenly  placed  toward  the  median 
Une. 


114 


PARALYSIS 


The  Twelfth  Nerve.— The  twelfth,  or  hypoglossal,  nerve  is  a 
motor  nerve  supplying  the  muscles  of  the  tongue  and  in  it  there  are 
branches  from  the  first  and  second  cervical  that  go  to  the  depres- 
sors of  the  hyoid.  The  diagnosis  is  easily  made,  inasmuch  as  the 
tongue  is  pushed  to  the  paralyzed  side  and  there  is  usually  marked 
atrophy  of  the  affected  part.  There  may  be  involvement  of  the 
muscles  of  the  lips,  usually  bilateral,  due  to  involvement  of  the  low- 
est cells  of  the  facial  nerve,  which  are  in  close  connection  with  the 
nucleus  of  the  hypoglossal. 


Fig.  41. — Left  facial  and  hypoglossal  paralysis.     Atrophy  of  left  side  of  tongue 
protrusion  to  the  left. 

The  Frequency  of  Cranial  Nerve  Affection. — Since  Medin  called 
attention  to  the  fact  that  the  cranial  nerves  might  be  involved, 
there  has  been  an  increasing  number  of  cases  reported.  As  early 
as  1836  Badham  noted  ocular  palsy.  There  are  probably  varia- 
tions in  different  epidemics.  In  1916,  in  a  small  epidemic  in  Balti- 
more, there  was  an  unusual  number  of  cranial  nerve  involvements. 
In  the  Swedish  epidemic  of  1905  Wickman  collected  42  cases  out 
of  685.     These  were  arranged  as  follows: 

Cranial  nerve  affections 

associated  with  spinal  Cranial  nerves 

nerve  affection.  alone  affected. 

VII 12  14 

XII 9  9 

Eyes 5  3 

VI         4  2 

III 4  2 

IX-XI 5  4 

V 2 

II 1 

42  34 


BULBAR  FORM  OF  PARALYSIS  115 

In  338  cases  at  the  Queensboro  Hospital,  in  the  New  York 
epidemic  of  191G,  there  was  cranial  nerve  involvement  in  46  cases, 
arranged  as  follows: 

Cranial  nerve 
affection. 

Optio 2 

Oculomotor 2 

Fourth 1 

Abducens 12 

Facial         26 

Glossopharjaigeal 2 

Hypoglossal 1 

46 

Conjugate  paralysis  of  eyes  in  2  cases. 

The  Bulbar  Form  of  Paralysis. — The  cases  which  show  localiza- 
tion in  the  pons  and  medulla  are  generally  called  cases  of  bulbar 
paralysis  and  those  cases  occurring  acutely  with  fever  are,  per- 
haps, to  be  regarded  as  poliomyelitis.  There  is  no  question  that 
both  from  a  pathological  and  epidemiological  point  of  view  that 
bulbar  paralysis  may  be  of  poliomyelitic  origin  and  be  the  only 
invohement.  More  frequently  it  is  associated  with  involvement  of 
the  spinal  cord,  and  such  cases  are  then  described  as  bulbospinal. 
We  have  considered  the  various  involvements  of  the  cranial  nerves, 
but  it  is  necessary  to  add  a  word  about  some  of  the  combinations. 
When  occurring  alone  or  in  connection  with  involvement  of  the 
spine,  the  bulbar  lesions  are  almost  invariably  unilateral,  although 
occasionally  bilateral  cases  have  been  reported.  All  sorts  of  com- 
binations may  be  observed,  the  commonest  form  being  the  facial 
paralysis  due  to  lesions  of  the  seventh  nerve.  There  may  be  vari- 
ous combinations  of  eye-muscle  affections,  either  alone  or  with 
other  paralyses,  and  there  may  be  changes  in  the  pupil;  sometimes 
there  is  nystagmus,  there  may  be  marked  changes  in  the  voice, 
varying  from  slight  hoarseness  to  complete  aphonia,  but  this,  in 
most  instances,  clears  up;  sometimes  it  may  be  of  very  transient 
duration.  There  may  be  slight  difficulty  in  swallowing,  there 
merely  being  a  tendency  to  have  the  food  enter  the  larynx,  or,  as 
children  usually  express  it,  to  swallow  the  wrong  way.  Sometimes 
liquids  can  be  swallowed  easily,  but  not  solid  food,  but  at  other 
times  the  inability  to  swallow  may  be  so  complete  as  to  necessitate 
gavage.  In  some  of  these  cases,  even  after  the  patient  has  been  fed 
for  five  to  ten  days,  the  ability  to  swallow  returns.  The  severity 
of  the  bulbar  cases  seem  to  be  greater  when  they  are  associated  with 
involvement  of  the  cord.    Curiously  enough  the  mortality  in  these 


116  PARALYSIS 

cases  does  not  seem  to  be  any  greater  from  the  close  proximity  of 
the  lesion  to  the  vital  centers  than  in  the  cases  in  which  the  lesion  is 
elsewhere.  In  some  instances  the  nerves  pass  through  the  pons 
and  medulla  and  seem  to  be  involved,  such  instances  having  been 
reported  by  Wickman,  Zappert,  Spieler,  Peabody,  Draper  and 
Dochez  and  others.  In  one  of  Wickman's  cases  there  was  involve- 
ment of  the  eye  muscles,  the  left  side  of  the  face,  the  right  side  of 
the  tongue,  and  a  cerebellar  ataxia.  In  another  case  there  was 
involvement  of  the  left  facial  and  hypoglossal,  with  slight  scanning 
in  speech,  some  ataxia  of  the  arms,  and  exaggeration  of  the  deep 
reflexes  of  the  legs.  Peabody,  Draper  and  Dochez  have  called  atten- 
tion to  the  slight  spastic  ataxia  which  this  type  of  cases  may  have, 
and  which  is  noted  under  the  heading  of  Ataxia. 

Deformities. — During  the  second  stage  of  the  disease,  sometimes 
even  during  the  first,  there  is  a  very  marked  tendency  to  deformity. 
The  ones  produced  by  gravity  and,  perhaps,  noted  the  earliest, 
such  as  toe-drop  and  foot-drop,  and  it  is  exceedingly  important  to 
try  to  prevent  this,  as  far  as  possible,  by  the  method  spoken  of  in 
the  treatment  of  the  disease.  The  second  factor  in  the  production 
of  deformity  is  having  one  muscle  or  one  group  of  muscles  paralyzed, 
and  as  a  result  of  there  being  no  resistance  to  the  opposing 
muscles,  the  tendons  and  muscles  are  gradually  stretched,  made 
abnormally  long  and  pulled  out  of  position  on  the  diseased  side 
and  correspondingly  shortened  on  the  healthy  side.  This,  if  left  to 
itself,  will  produce  the  most  extraordinary  deformities,  as  may  be 
seen  in  the  various  illustrations.  If  all  the  muscles  are  paralyzed  a 
flail-joint  usually  results.  As  time  goes  on  and  the  child  grows, 
two  other  factors  enter  into  the  deformity;  the  flrst,  the  atrophy  of 
all  the  tissues,  including  even  the  bones,  and  the  efi^ect  of  growth, 
the  two  together  often  producing  most  remarkable  results.  The 
growth  of  both  joints  and  muscles  is  along  the  line  of  least  resis- 
tance, so  that  the  long  bones  may  be  bent  out  of  shape,  the  joints 
distorted  sometimes  beyond  recognition,  and  there  may  be  atrophy 
with  this,  so  that  at  first  sight  it  may  be  exceedingly  difficult  to 
orient  oneself.  The  longer  this  is  allowed  to  go  on  without  any 
treatment  the  worse  it  gets,  and  in  some  cases  even  with  treatment 
the  deformity  may  reach  most  discouraging  proportions.  The 
paralyzed  extremities  may  grow  at  a  very  much  less  rapid  rate 
than  those  on  the  good  side,  and  there  may  be  a  very  considerable 
shortening  as  a  result.  This  may  come  on  within  a  very  few  months, 
even  as  much  as  half  an  inch  to  an  inch  may  be  noted  in  this  length 


bjEP'ORMltlES  11? 

of  time.  Seeiigmiiiler  called  attention  to  the  elongation  of  tlie  bones 
of  the  leg  which  he  believed  to  be  due  to  the  epiphyses  suffering 
retraction  instead  of  the  normal  compression.  Sometimes  the 
lengthening  is  real,  at  others  only  apparent.     The  bones  themselves 


Fig.  42. — Old  anterior  poliomyelitis;  hypoplasia  of  the  right  half  of  the  shoulder- 
girdle,  thorax,  and  right  upper  extremity.  (From  the  Medical  Clinic  of  the  Montreal 
General  Hospital.) 

are  apparently  not  more  liable  to  fracture  than  normal  bones,  but 
there  is  a  relative  increase  of  the  medullary  part.  The  skin,  espe- 
cially in  the  older  cases,  usually  adheres  to  the  connective  tissue 
under  it,  and  the  difference  in  temperature  of  the  good  and  affected 


118 


Paralysis 


side  may,  in  some  cases,  be  as  much  as  ten  degrees.  The  skin  and 
tissues  heal  rapidly  after  operation  and  fractures  and  unite  the  same 
as  a  normal  bone. 

When  one  has  made  a  diagnosis  of  the  nature  and  extent  of  the 
paralysis  the  deformity  that  will  result  from  neglect  can  easily  be 
foretold.  The  results  seem  to  be  pretty  uniformly  the  same,  and 
depend  upon  the  muscle  paralysis  and  the  extent  of  the  paralysis. 
The  deformities  that  occur  will  be  found  largely  as  follows :  Those 
of  the  foot  are  taken  from  an  article  by  Lucas  and  Lovett.^ 


Foot. 


Varus 

Peronei. 

Anterior  tibial. 

Posterior  tibial. 

Valgus 

Flexor  longus  hallucis. 

Both  tibials. 

,  Whole  leg. 

Equinus 

Anterior  muscles  paralyzed  or  weak. 

Complete  paralysis. 

Anterior    muscles   with    persistence    of   flexor   longus 

Eqxiinovarus 

hallucis. 

Anterior  and  external  group. 

Eauinovalaus                           /  -^"^terior  and  internal  muscles. 

\  Anterior  muscles  and  weight-bearing. 

Calcaneous 

Posterior  muscles. 

Calcaneovalgus 

Posterior  muscles  and  one  or  both  tibials. 

Knee. 

Genurecurvatum 

Posterior  thigh  muscles. 

Permanent  flexion 

Quadriceps. 

Hip. 

Luxation 

See  dislocations. 

Permanent  flexion 

Extensors  of  thigh. 

Permanent  adduction 

Glutei. 

Hand. 

Flexion  of  fingers  and  wrist     Paralysis  of  all  extensors. 
Extension  of  wrist  Flexors  of  forearm. 

Claw-hand  Extensors  of  forearm. 


Elbow. 

No  deformity  (Seeligmiiller) . 

Shoulder. 

Subluxation  Deltoid. 

>  Jour.  Am.  Med.  Assn.,  November  14,  1908. 


DISLOCATIONS 


119 


Trunk. 

Dorsal  scoliosis  Paralysis  of  one  side  of  back  muscles  or  other — erector 

spinse  group. 
Kyphosis  Extensor  of  back. 

Lordosis  Abdominal  muscles. 

Dislocations. — The  only  joint  that  suffers  with  a  true  dislocation 
is  the  hip,  but  there  may  be  looseness  of  the  muscles  and  of ,  the 
joint  capsule  of  some  of  the  others.  These  may  gradually  be 
stretched  by  the  force  of  gravity  until  the  bones  are    completely 


Fig.  43. — Anterior  pohomyelitis.     Extreme  flexion  deformity  at  the  hips,  inducing 
Quadrupedal  locomotion.     (Gibney.) 

pulled  out  of  place.  This  is  well  illustrated  in  the  cases  of  paralysis 
of  the  deltoid,  in  which  there  may  be  a  subluxation  of  the  humerus. 
In  the  hip,  in  a  case  of  extensive  paralysis  of  the  muscles  about  it, 
there  may  be  a  very  loose  capsule  and  either  a  partial  or  complete 
dislocation  when  the  leg  is  adducted,  or  when  it  is  moved  upward 
or  downward.  Forward  dislocations  have  been  described,  but  are 
apparently  very  rare.^    In  some  instances  the  bone   forms  a  new 


1  Sever:  Boston  Med.  and  Surg.  Jour.,  August  31,  1911. 


120 


PARALYSIS 


Fig.  44. — Poliomyelitis,  causing  gemirecurvatum,     (Whitman.) 


Fig.  45. — Poliomyelitis.     Paralj^sis  of  muscles  at  the  hip  allows  subluxation  of  the 

femur.     (Whitman.) 


DISLOCATIONS  121 

socket  which  may  be  of  more  or  less  service.  In  others  there  is  a 
partial  socket  formed  from  which  the  head  of  the  bone  slips  about 
and  in  some  there  may  be  a  very  remarkable  atrophy,  even  going 
as  far  as  to  have  complete  disappearance  of  the  head  of  the  bone. 


Fig.  46. — Onset  at  eighteen  months.  No  attempt  at  preventing  deformity. 
Patient  aged  twelve.  Walked  on  his  hands.  Condition  on  entrance  to  Children's 
Hospital  School,  Baltimore. 

The  diagnosis  is,  perhaps,  best  made  by  the  .r-ray  examination,  but 
the  same  rules  used  in  determining  ordinary  dislocations  may  be 
applied,  especially  the  shortening  and  the  trochanter  being  above 
Nelaton's  line. 


CHAPTER  VIII. 
SPECIAL  FEATURES  AND  SYMPTOMS. 

The  Incubation  Period. — The  incubation  period  in  the  experimental 
disease  as  produced  in  monkeys,  varies  from  two  days  to  over  six 
weeks,  but  usually  they  develop  the  disease  within  two  days  to  two 
weeks.  The  incubation  period  in  the  human  being  is  usually  short, 
generally  under  eight  days.  It  has  been  variously  asserted  by 
various  observers.  Wickman  places  it  at  from  one  to  four  days, 
Miiller  at  from  five  to  ten  days,  with  an  average  of  about  a  week, 
whereas  Flexner  puts  it  at  from  two  days  to  two  weeks,  or  occa- 
sionally longer. 

Onset  without  Prodromata. — In  about  5  per  cent,  of  the  cases  the 
paralysis  may  be  the  first  symptom  noted.  In  a  very  small  propor- 
tion of  these  cases  there  does  not  appear  to  have  been  any  preceding 
symptoms  of  any  kind,  but,  as  a  rule,  if  the  history  can  be  obtained 
it  will  be  found  that  there  has  been  slight  fever  or  vomiting  or  some 
other  sign  of  indisposition.  In  many  cases,  owing  to  the  ignorance 
or  carelessness  of  the  parents,  slight  symptoms  are  ignored,  and  the 
loss  of  power  therefore  given  as  the  onset  of  the  disease.  In  some  of 
these  cases  the  usual  symptoms  of  the  disease  may  make  their 
appearance  after  the  onset  of  the  paralysis. 

Cases  with  Remissions  of  Symptoms  and  Delayed  Paralysis. — In 
the  preparalytic  stage  there  is  not  infrequently  a  remission  of 
symptoms  with  a  subsequent  recurrence.  The  remission  generally 
lasts  a  day  or  two  and  then  the  symptoms  return  in  a  more  intense 
form.  We  have  seen  children  who  were  said  to  have  been  in  bed  a 
day  or  two  and  out  on  the  street  the  next  day,  and  on  the  following 
day  profoundly  ill  with  the  onset  of  paralysis  within  a  very  short 
time.  A  similar  remission  may  occur  after  the  child  is  paralyzed. 
There  may  be  a  decided  betterment  both  in  the  general  symptoms 
and  sometimes  in  the  paralytic  condition,  and  also  in  the  changes 
in  the  spinal  fluid,  and  then  after  one  or  several  days  there  may 
be  a  recrudescence  of  the  fever  and  the  symptoms,  a  greater  loss 
of  power,  and  return  of  abnormal  changes  in  the  spinal  fluid. 

Relapses  or  Recurrences. — There  have  been  a  few  curious  instances 
reported  by  various  observers,  including  Medin,  Leegaard,  Auer- 


fEMPERATURE  123 

bach,  Xeurot,  Forster,  and  Schwartz,  in  which  after  a  child  appar- 
ently had  recovered  from  an  attack  and  after  an  interval  of  even 
weeks  or  months  there  was  a  recurrence  of  the  disease  with  increased 
paralysis.  The  nature  of  these  cases  is  not  definitely  understood; 
whether  it  is  simply  a  flaring  up  of  the  original  infection  or  whether 
the  first  attack  did  not  produce  an  immunity  and  the  child  suffered 
with  a  subsequent  infection.  In  any  event  they  are  of  very  rare 
occurrence. 

Second  Attacks. — The  immunity  produced  by  one  attack  of  the 
disease  seems  to  be  almost  perfect,  but  there  are  instances  on 
record  in  which  very  definite  second  attacks  have  occurred  in  indi- 
viduals who  previously  had  the  disease.  Two  such  cases  occurred 
in  the  Xew  York  epidemic  of  1916.  These  cases  should,  perhaps, 
be  distinguished  from  the  relapses  or  recurrences.  (See  same.) 
Eshner^  has  made  a  study  of  this  subject  and  also  refers  to  the 
other  nervous  diseases  which  may  occur  after  poliomyelitis.  Most 
of  the  cases  that  have  been  reported  would  come  under  this  class. 
Eshner,  however,  reports  a  case  in  which  eleven  years  elapsed 
between  the  two  attacks.  The  first  case  was  undoubted  polio- 
myelitis. The  second  attack,  which  occurred  at  thirteen  and  a 
half  years,  attended  with  weakness  and  wasting  in  both  hands, 
transitory  on  the  right  side  and  persistent  on  the  left.  It  was  some- 
what doubtful,  inasmuch  as  it  followed  an  injury  due  to  a  fall,  and 
the  paralysis  may  possibly  have  been  of  peripheral  origin  rather 
than  spinal. 

The  Temperature. — Fever  is  the  most  constant!}'  observed  s\Tnp- 
tom,  and  we  are  of  the  opinion  that  the  so-called  afebrile  cases  are 
merely  those  in  which  the  febrile  period  has  been  transient  and 
overlooked.  It  is  important  to  note  that  the  height  of  the  tem- 
perature and  the  ultimate  outcome  of  the  case  bear  no  relation  to 
each  other.  There  may  be  extremely  high  fever,  particularly  at 
the  onset,  and  the  child  may  recover  entirely,  while  in  other  cases 
with  the  most  extensive  paralysis  the  temperature  may  never  be 
very  high.  The  temperature,  as  a  rule,  starts  at  the  beginning  of 
the  disease  and  varies  between  101°  and  104°;  in  some  cases  the 
temperature  is  even  more  than  this,  while  in  others  there  may  be 
hyperpyrexia,  105°  to  106°  or  even  more.  Temperature,  as  a  rule, 
does  not  last  long,  usually  from  two  to  five  days,  sometimes  seven 
or  eight,  and,  very  rarely,  for  ten.     It  may  fall  to  normal  rather 

1  Med.  Record,  September  24,  1910,  p.  52G. 


124  SPECIAL  FEATURES  AND  SYMPTOMS 

suddenly  or  it  may  drop  gradually  with  decided  oscillations.  Some- 
times the  temperature  drops  below  the  normal  and  may  remain 
subnormal  for  several  days  or  even  several  weeks.  In  other  cases 
the  temperature  does  not  quite  reach  the  normal  point,  although 
it  is  near  it,  and  this  may  also  persist  for  days  or  even  for  weeks, 
but  without  any  apparent  effects.  In  a  considerable  number  of 
cases,  the  so-called  dromedary  cases  of  Draper,  the  temperature 
returns  to  normal  and  then  goes  up  again,  usually  with  the  onset 
of  paralysis.  In  some  of  the  cases  in  which  there  is  paralysis  the 
temperature  may  reach  normal  or  near  it,  and  then  after  several 
days,  usually  four  or  more,  there  is  a  recrudescence  of  the  fever, 
with  an  increase  in  the  paralysis  and  general  symptoms.  A  curious 
thing  about  many  of  the  cases  is  that  they  do  not  look  as  though 
they  had  temperature,  but  on  taking  it,  it  is  found  to  be  above 
normal. 

Prostration. — There  are  great  variations  in  the  amount  of  pros- 
tration present;  in  some  there  may  be  little  or  none,  whereas  in 
others  it  may  be  very  marked.  In  some  instances  the  prostration  is 
pronounced,  even  from  the  first;  it  may  be  continuous  or  it  may 
remit,  and  the  child  be  up  and  about  and  then  have  to  go  to  bed 
again.  In  the  milder  cases  the  condition  passes  off  quickly,  whereas 
in  the  severer  ones  it  may  last  a  week  or  even  two  weeks. 

Stupor. — Unfortunately,  many  authors  have  used  the  term 
encephalitic  or  cerebral  and  have  applied  that  to  all  cases  with 
stupor.  These  terms  are  best  limited  to  the  cases  in  which  there 
are  lesions  of  the  upper  neurons  with  spastic  paralysis  as  first 
described  by  Striimpell.  (See  same.)  The  ordinary  paralyses  are 
due  to  either  bulbar  or  spinal  lesions,  or  both,  and  the  stuporous 
cases  may  be  regarded  as  belonging  to  this  type  with  the  added 
.mental  condition.  Whether  these  changes  are  due  to  the  changes 
in  the  blind  areas  of  the  brain  or  not  has  not  been  definitely  settled 
at  this  time.  These  patients  may  be  in  profound  coma,  with  open 
eyes,  an  expressionless  mask-like  face,  and  slight  retraction  of  the 
head.  In  others  the  condition  is  not  so  bad,  but  the  child  is  in  a 
very  profound  sleep,  with  the  eyes  moving  slowly  under  the  closed 
lids.  In  a  general  way  they  resemble  very  closely  cases  of  tuber- 
culous meningitis,  and  the  diagnosis  between  the  two  conditions 
may  be  a  matter  of  considerable  difficulty.  The  child  can  generally 
be  aroused  partially,  and  if  not,  when  disturbed,  it  shrugs  the  shoul- 
ders or  moves  the  arms  or  head,  showing  distinct  irritability,  and 
as  soon  as  undisturbed  relapses  into  its  state  of  coma.     In  others 


DELIRIUM  125 

the  condition  is  less  stuporous,  and  they  merely  have  the  appearance 
of  a  child  in  a  profound  sleep,  such  as  might  be  induced  by  nar- 
cotics. This  condition  usually  lasts  from  three  to  six  days,  and  the 
child  may  come  out  of  it  suddenly  just  as  if  it  had  been  asleep  for 
that  period  of  time,  or  more  often  the  return  to  consciousness  is 
gradual,  occupying  a  matter  of  hours  or  even  a  day  or  more.  There 
does  not  seem  to  be  any  relation  of  the  stupor  to  the  temperature. 
Cases  with  high  fever  may  have  little  or  none,  and,  on  the  other 
hand,  some  of  the  most  profoundly  comatose  may  have  little  or 
no  fever. 

Headache. — This  is  one  of  the  commonest  symptoms,  and  is  met 
with  in  practically  all  cases  in  which  the  child  is  old  enough  to 
describe  sensations.  In  most  instances  the  headache  is  of  mod- 
erate severity,  but  at  times  may  be  very  intense,  suggesting  that 
seen  in  meningitis.  The  pain  may  be  over  the  entire  head,  but  is 
often  limited  either  to  the  frontal  or  occipital  regions.  The  patient 
often  complains  of  pain  in  the  back  of  the  head  and  the  neck. 

Delirium.^ — As  a  rule  the  mental  condition  is  one  of  somnolence; 
the  patient  may  be  delirious,  although  this  is  usually  of  short  dura- 
tion and  not  very  severe.  The  more  common  condition  is  a  mental 
confusion  like  that  seen  in  meningitis.  Of  more  importance  is  a 
condition  of  mental  exultation  which  we  have  occasionally  seen 
and  which  apparently  is  of  very  grave  import.  The  patient,  who 
may  be  profoundly  ill,  in  place  of  being  somnolent  or  confused  is 
talkative,  is  excited  and  sleepless.  In  all  instances  which  we  have 
seen  in  which  the  patient  was  very  ill  and  in  which  this  condition 
existed  there  has  been  a  fatal  outcome.  In  adults  and  older  children 
there  is  occasionally  a  stage  of  excitement  which  may  be  noted  at 
the  onset  and  which  is  out  of  all  proportion  to  the  other  symp- 
toms. There  is  a  vague  anxiety  of  some  great  impending  evil, 
together  with  mental  disturbance;  a  state  somewhat  suggesting 
the  condition  of  a  person  with  beginning  rabies,  a  point  which  may 
be  borne  in  mind  in  considering  the  diagnosis.  Restlessness  and 
irritability  are  very  common  and  pronounced  symptoms,  and  may 
be  the  first  thing  noted.  As  a  general  rule  the  child  will  be  quiet 
and  only  restless  and  irritable  w^hen  disturbed,  but  in  other  cases 
there  is  a  very  marked  restlessness,  especially  at  the  outset,  and  the 
patient  may  move  about  in  the  bed  from  side  to  side  and  up  and 
down  and  getting  up  and  down  again  and  again  in  a  perfectly 
purposeless  manner.  This  in  itself  we  regard  as  a  very  suggestive 
sjinptom. 


126  SPECIAL  FEATURES  AND  SYMPTOMS 

Convulsions. — ^While  general  convulsions  are  not  often  seen, 
although  they  may  occur  at  the  onset,  especially  in  young  children, 
Medin  thought  they  occur  only  in  cases  that  turn  out  to  be  enceph- 
alitic;  but  there  are  certainly  exceptions  to  this.  They  have  occa- 
sionally been  noted  in  the  course  of  the  disease  and  preceding  the 
ataxic  sjrmptoms. 

In  the  Hesse-Nassau  epidemic  there  were  a  number  of  cases  in 
which  there  were  epileptiform  seizures  without  loss  of  consciousness, 
and  also  more  tonic  spasms.  Miiller  has  reported  an  instance  in 
which  there  was  severe  epileptiform  convulsions  with  unconscious- 
ness. 

Twitching. — Twitching  of  the  muscles  is  comparatively  common. 
It  may  consist  of  a  quick  contraction  of  an  individual  muscle  or  of 
a  group  of  muscles,  sometimes  of  an  entire  extremity.  It  is  usually 
noted  early  in  the  disease  before  the  onset  of  the  paralysis.  There  is 
a  faint  fibrillary  twitching  of  the  muscle  fibers,  frequently  noted  in 
connection  with  vasomotor  disturbances,  which  is  exceedingly 
suggestive  and  is  often  seen,  particularly  in  the  meningitic  type. 

Tremor. — ^Attention  was  called  to  tremor  by  Wickman,  and  may 
have  certain  value  in  diagnosis  in  the  early  cases.  It  is  seen  in  the 
initial  stage,  is  perhaps  best  observed  in  the  hands,  and  consists  of 
a  slight,  intentional  tremor,  which  is  absent  in  repose. 

Nystagmus. — This  has  been  noted  frequently  in  connection  with 
paralysis  of  some  of  the  cranial  nerves  and  in  cases  with  ataxia,  and, 
perhaps,  occurs  independently  of  either.  The  condition  is  usually 
transitory  and  the  nature  of  the  central  lesion  producing  it  is  not 
perfectly  clear. 

Reflexes. — ^The  deep  reflexes  are  absent  when  there  is  complete 
paralysis  and  may  be  diminished  when  there  is-  partial  paralysis. 
In  the  true  cerebral  type  of  the  disease  the  deep  reflexes  may  be 
exaggerated  and  Babinski's  sign  present. 

Disturbances  of  Taste. — ^As  far  as  we  know  these  have  never  been 
studied,  but  it  would  seem  highly  probable  that  in  affections  of 
the  fifth  or  ninth  nerves  that  they  would  occur.  In  older  children 
and  adults  studies  might  easily  be  undertaken,  and  the  results 
would  be  extremely  interesting. 

Speech  Disturbances. — ^Apart  from  the  disturbances  of  speech 
mentioned  under  the  heading  of  Bulbar  Paralysis,  there  are  other 
but  little  studied  affections.  Among  these  may  be  mentioned 
scanning  speech,  similar  to  that  which  one  sees  in  multiple  sclerosis. 
This  is  usually  transitory,  and  is  generally  seen  in  the  cases  in  which 


PAIN  127 

there  is  ataxia.  We  have  under  observation  one  child,  three  years  of 
age,  with  the  most  distinct  scanning  speech  that  it  has  had  ever 
since  it  could  talk,  the  paralysis  coming  on  at  the  end  of  the  first 
year.  In  addition  to  this  the  child  has  a  slight  spastic  paralysis  with 
marked  increase  in  the  tendon  reflexes  and  very  marked  ataxia, 
being  unable  to  walk  or  stand  without  assistance. 

The  other  disturbances  of  speech  are  probably  very  rare  and  have 
attracted  but  little  attention. 

Pain. — Pain  or  tenderness  is  one  of  the  striking  features  of  the 
disease.  This  has  been  noted  in  practically  all  epidemics  as  well  as 
in  the  sporadic  cases.  In  the  Xew  York  epidemic  of  1907  the  pain 
was  distributed  as  follows: 

Lower  extremities 248 

Upper  extremities 49 

Trunk  and  spine 104 

In  the  neck 27 

In  the  face .  1 

General  hyperesthesia 4.3 

In  the  Massachusetts  epidemic  of  1910  the  pain  and  tenderness 
was  present  in  184  cases  and  absent  in  16.  A  more  careful  study  of 
this  symptom  than  its  mere  location  or  occurrence  shows  that  there 
are  a  number  of  different  sorts  of  painful  sensations.  There  may  be 
spontaneous  pain,  there  may  be  pain  on  pressure  of  the  muscles  or 
nerve  tracts,  there  may  be  hyperesthesia  of  the  skin,  and  perhaps 
most  important  from  the  standpoint  of  diagnosis,  pain  may  be 
elicited  by  any  motion  which  tends  to  bend  the  spine,  such  as  testing 
for  Kernig's  sign  or  in  bending  the  head  forward  upon  the  chest. 
These  motions  almost  invariably  elicit  pain,  and  the  patient  resists 
attempts  to  flex  the  legs  on  the  abdomen  or  to  bend  the  head  forward 
or  to  have  the  spine  flexed.  The  patient  often  fears  this  pain  may 
be  produced  and  may  lie  with  the  head  somewhat  thrown  back  and 
the  spine  somewhat  extended. 

The  spontaneous  pain  is  extremely  variable.  Some  cases  are  seen 
in  which  there  is  no  pain  whatever  tliroughout  the  whole  course  of 
the  disease,  while  in  others  the  pain  may  be  of  the  most  intense 
character,  and  in  the  same  way  there  are  great  variations  in  the 
length  of  time  the  pain  lasts;  it  may  be  transient,  and  consist  of 
lightning-like  stabs  of  pain,  or  it  may  be  constant  and  may  last 
from  a  few  hours  to  a  few  days,  and,  in  some  instances,  as  long  as 
six  weeks,  and  occasionally  even  longer.  In  most  instances  in  which 
recovery  from  the  paralysis  takes  place  early  the  spontaneous  pain 


128  SPECIAL  FEATURES  AND  SYMPTOMS 

has  disappeared  by  the  time  the  power  has  returned.  The  cases  in 
which  the  paralysis  is  of  longer  duration  the  pain  has  usually  ceased 
in  from  one  to  three  weeks.  In  some  patients  the  pain  is  not  very 
definitely  localized,  particularly  in  the  younger  children;  in  some 
it  seems  to  follow  the  nerve  tracts  or  certain  peripheral  nerves  and 
suggests  a  neuritis,  and  when  this  is  the  dominant  feature  it  has 
given  rise  to  a  special  classification  of  polyneuritic  cases.  Headache 
is  also  a  spontaneous  pain,  especially  noted  at  the  onset  of  the 
disease. 

The  pain  produced  by  motion  is  apt  to  keep  the  children  prone  for 
days  or  weeks.  In  ordinary  cases  of  illness  in  children,  as  soon  as 
the  child  feels  the  least  bit  better  it  wants  to  sit  up  and  move  about. 
In  poliomyelitis  the  children  are  perfectly  content  to  lie  and  play 
with  such  simple  toys  as  they  may  be  able  to  handle.  They  may  be 
perfectly  contented  as  long  as  they  are  let  alone,  but  as  soon  as  they 
are  approached  they  show  every  evidence  of  fear  of  being  disturbed 
or  an  attempt  to  make  them  move. 

In  some  cases  there  is  very  definite  tenderness  or  pain  to  be 
elicited  by  firm  pressure  on  the  muscles  or  firm  pressure  over  the 
nerves,  and  this  may  exist  without  any  tenderness  of  the  skin.  In 
other  cases  there  is  definite  hyperesthesia,  and  the  patient  cries 
out  at  the  merest  touch  to  the  skin.  These  areas  may  be  more  or 
less  localized  or  the  condition  may  seem  to  extend  through  most 
of  the  body.  It  seems  to  be  particularly  present  in  the  legs.  In 
some  instances  the  child  cannot  bear  the  pressure  of  the  bedclothes, 
and  wire  frames  have  to  be  supplied  to  keep  the  clothing  from  coming 
in  contact  with  the  skin. 

This  whole  subject  of  pain  in  poliomyelitis  could  be  restudied 
with  advantage.  In  most  epidemics  there  has  been  so  much  thrown 
on  the  physicians  and  nurses  that  only  superficial  studies  have  been 
undertaken  in  most  instances. 


Pain  and  Tenderness.    Massachusetts  Epidemic  of  1910. 

Cases. 

Pain  or  tenderness  was  present  in        . .      .     469 

Pain  or  tenderness  was  absent  in 42 

Pain  or  tenderness  was  not  stated  in 90 

601 


OTHER  SENSORY  DISTURBANCES  129 

Pain  or  Tenderness  Lasted. 

Casns. 

No  pain 42 

One  da\-  or  less 9 

Two  cla\'s 14 

Three  days 20 

Four  days 15 

Five  days 10 

Six  days , 6 

One  week 35 

One  to  two  weeks 41 

Two  to  three  weeks 32 

Three  to  four  weeks 18 

Four  to  five  weeks 8 

Five  to  six  weeks 4 

Eight  to  nine  weeks 5 

Nine  to  ten  weeks 1 

A  few  days 25 

Until  death 45 

Present  when  report  was  made 181 

Not  stated 90 

601 

Disappear-\nce  OF  Pain  and  Tenderness  (1909-10).    Massa- 
chusetts Epidemic  of  1910. 

Cases.  Per  cent. 

One  day  or  less 11                   1.82 

Two  days 22  3 .  64 

Three  days 29  4.801 

Four  days 15  2.48 

Five  days 14  2.31 

Six  days 3  0.496 

A  few  da j's 28  4 .  63 

One  week .  59  9 .  76 

One  to  two  weeks 91  15.06 

Two  to  thi-ee  weeks 46  7.61 

Three  to  four  weeks 33  5 .  46 

Four  to  five  weeks 1  0.16 

Six  to  seven  weeks 1  0.16 

One  to  two  months 28  4 .  63 

Two  to  three  months 5  0 .  82 

Several  months    . 3  0 .  496 

Until  death 39  6.45 

Present  when  report  was  made 175  29.13 

Total 603 

Other  Sensory  Disturbances. — These  have  not  been  studied  either, 
except  by  comparatively  few  observers,  and  not  with  any  very  great 
degree  of  thoroughness.  Various  paresthesias  have  been  described 
and  older  children  and  adults  sometimes  complain  of  numbness. 
Wickman  relates  a  case  in  which  there  was  diminution  of  the  pain 
sense  from  the  hips  down  and  paresthesia  of  both  legs.  It  is  inter- 
esting to  note  that  in  this  case  the  feet  showed  a  definite  diminution 
of  temperature  sense  of  the  feet.    Other  cases  have  been  described 


130  SPECIAL  FEATURES  AND  SYMPTOMS 

in  which  there  was  complete  anesthesia,  and  loss  of  electric  reaction 
has  also  been  noted.  We  are  so  accustomed  to  thinking  of  polio- 
mj^elitis  as  a  disease  affecting  the  motor  part  of  the  nervous  system 
that  in  spite  of  the  mass  of  evidence  to  the  contrary  the  sensory  side 
of  the  nervous  system  has  been  very  largely  neglected. 

Sweating, — ^This  is  very  common  and  varies  from  a  moderate 
perspiration  to  intense  colliquative  sweats  involving  the  whole 
body.  It  very  often  happens  that  this  sweating  is  limited  to  certain 
areas;  to  the  face  or  neck,  sometimes  to  one-half  of  the  face,  to  one 
extremity,  to  the  hands  and  feet.  As  the  patient  recovers  the 
sweating  usually  disappears,  but  it  occasionally  may  persist  for  some 
time  as  a  disagreeable  feature.  There  is  apparently  no  relation 
between  the  sweating  areas  and  the  paralysis. 

Dry  Skin. — Higier  has  described  a  few  cases  in  which  there  was 
unusual  dryness  of  the  skin  of  the  paralyzed  extremities. 

Eruptions. — There  is  no  typical  eruption  of  poliomyelitis,  although 
some  authors  have  described  skin  eruptions  in  connection  with  the 
disease.  Erythema  of  an  irritative  type  may  be  noted,  particularly 
about  the  head,  neck,  or  chest,  but  this  is  usually  more  or  less  tran- 
sient, and  is  of  very  common  occurrence  in  sick  children  who  have 
fever,  without  reference  to  the  cause.  Of  course,  complicating  skin 
diseases  may  be  noted,  most  commonly  itch,  pediculosis,  the  result 
of  mosquito  bites,  and  eczema  from  the  lack  of  care.  The  paralyzed 
extremities  are  usually  cold  and  show  a  bluish-white  mottling.  In 
cases  with  meningeal  symptoms  the  tdche  cerebrale  may  be  noted 
after  stroking  the  skin.  First  a  red  line  appears  and  then  the  center 
of  this  red  line  becomes  lighter,  while  the  edges  remain  red.  In 
other  cases  there  is  simply  a  red  line  which  fades  quickly,  and  there 
is  frequently  alternating  blushing  and  paling  of  certain  areas  of 
the  skin.  These  may  be  of  very  short  duration  or  may  last  for  a 
considerable  length  of  time. 

Herpes,  usually  of  the  lips,  has  been  occasionally  noted.  It  is 
apparently,  however^  rare  in  poliomyelitis,  and  this  was  formerly 
suggested  as  a  differential  point  between  it  and  cerebrospinal  fever. 

Joint  Swellings. — Occasionally  swelling  of  the  larger  joints  have 
been  noted  in  the  course  of  poliomyelitis.  Such  cases  have  been 
noted  by  Wickman,  Hoffman  and  Spieler.  The  chief  importance 
of  this  complication  is  the  possibility  of  mistaking  the  disease  for 
an  acute  rheumatism  or  arthritis. 

Emotional  States  during  Convalescence. — The  psychology  of  these 
convalescent  patients  is  very  interesting.    As  far  as  we  know,  very 


URINE  131 

little  has  been  done  in  regard  to  special  study,  but  the  most  casual 
observer  will  note  certain  definite  changes.  Fortunately,  these 
are  only  transient,  lasting  onh'  a  few  days  or  a  few  weeks  at  most. 
Occasionally,  abnormal  emotional  states  may  persist  for  long  periods 
of  time,  but  these  are,  perhaps,  not  due  to  the  action  of  the  virus 
of  the  disease  but  to  the  loss  of  power  and  consequent  abnormal 
condition  of  the  child,  similar  chronic  conditions  being  met  with  in 
crippling  from  any  cause.  In  the  convalescing  poliomyelitis  patients 
some  will  be  found  to  be  normal  and  bright ;  in  others  there  is  a  very 
marked  tendency  to  laugh  or  giggle  or  cry  from  very  slight  causes, 
or  often  for  no  reason  at  all.  In  others  there  is  a  continuous  con- 
dition of  irritability  and  fretfulness,  the  child  cries  a  great  deal  and 
objects  very  seriously  to  being  interfered  with,  even  after  the  painful 
stage  of  the  disease  has  disappeared.  In  still  others  there  is  a 
condition  of  sullenness  or  moroseness,  as  if  the  child  had  been  made 
angr}'  and  had  not  gotten  over  it. 

The  Blood.^ — The  most  complete  studies  on  the  blood  have  been 
made  by  Peabody,  Draper  and  Dochez,  in  their  monograph  which 
was  published  by  the  Rockefeller  Institute  in  1912.  The  blood  does 
not  show  anything  characteristic,  but  merely  suggests  that  there 
is  an  infection  in  the  body.  There  is  a  constant  and  marked  increase 
in  the  leukocytes,  generally  a  polymorphonucleosis,  and  sometimes 
there  is  an  increase  in  the  lymphocytes.  The  increase  in  the  total 
number  of  cells  may  be  as  high  as  30,000.  There  is  generally  an 
increase  in  the  polynuclears  of  from  10  to  15  per  cent.,  and  a  diminu- 
tion of  the  lymphocytes  of  from  15  to  20  per  cent.  In  one  case  a 
marked  leukopenia  was  noted.  The  blood  cells  themselves  present 
no  abnormal  pictures.  The  blood  picture  is  so  variable  as  not  to 
afford  any  information  of  value  as  regards  diagnosis.  Hogue  and 
Cepelka^  believe  that  the  question  of  how  long  the  child  should 
be  kept  at  rest  before  beginning  massage  and  exercises  may  be 
solved  by  observing  the  white  blood  count.  They  suggest  that 
manipulative  procedures  may  be  begun  as  the  leukocAlosis 
disappears.  This  return  to  the  normal  varies  in  dift'erent  patients, 
three  or  more  weeks  usually  elapsing  before  the  blood  picture  is 
what  it  was  before  the  patient  was  taken  with  the  disease. 

The  Urine. — Retention  of  the  urine  may  be  noted  and  should 
always  be  looked  for.  In  some  cases  it  may  be  sufficient  to  require 
catheterization,  but,  as  a  rule,  this  does  not  last  any  great  length  of 

1  Jour.  Am.  Med.  Assn.,  August  26,  1916,  p.  666. 


132  SPECIAL  FEATURES  AND  SYMPTOMS 

time.  Sometimes  there  is  only  difficulty  in  starting  the  micturition, 
which  is  usually  easily  remedied  by  hot  applications,  by  placing 
the  child  in  a  hot  sitz  bath  or  on  a  vessel  partly  filled  with  hot  water. 
In  comatose  cases  there  may  be  incontinence,  but  this  seems  to  be 
rather  rare. 

The  Glycosuria. — Peabody,  Draper  and  Dochez  have  noted  two 
instances  in  which  the  spinal  fluid  had  an  exceptionally  high  power 
to  reduce  Fehling's  solution.  One  of  these  patients  also  had  a  glyco- 
suria, and  it  is  possible  that  a  lesion  between  the  nuclei  of  the  eighth 
and  tenth  nerve  may  have  had  the  same  effect  as  the  "  sugar  punc- 
ture" of  Claude  Bernard,  and  so  caused  a  hyperglycemia. 

The  Respiratory  Tract. — The  respiratory  symptoms  with  polio- 
myelitis are  exceedingly  variable  in  some  cases;  they  may  be  very 
pronounced  and  in  others  absent  entirely.  There  is  not  only  a  vari- 
ation in  the  individual  cases,  but  in  epidemics.  For  example,  in  the 
Hesse-Nassau  epidemic  in  1908  over  50  per  cent,  of  the  cases  showed 
marked  respiratory  involvement.  In  some  instances  the  disease 
comes  on  with  coryza  and  a  sore  throat  and  some  bronchitis,  so  that 
it  may  be  mistaken  for  an  attack  of  grippe.  Often  with  this  there 
may  be  a  slight  conjunctivitis  which  aids  in  making  the  error. 
In  some  instances  there  is  bronchopneumonia,  and,  less  often,  a 
lobar  pneumonia  as  a  complication,  and  this  is  most  apt  to  happen 
in  cases  in  which  there  has  been  some  involvement  of  the  inter- 
costals  or  diaphragm.  In  some  instances  in  which  the  respiratory 
muscles  have  been  paralyzed  the  lung  shows  signs  of  pulmonary 
edema.  It  may  be  extremely  difficult  to  tell  whether  one  is  dealing 
with  a  bronchopneumonia  or  a  temporary  effusion  into  the  lung. 
If  the  patient  lives  the  diagnosis  usually  becomes  apparent  after  a 
day  or  two. 

The  Heart. — The  heart  behaves  in  poliomyelitis  very  much  as 
it  does  in  any  acute  infectious  disease.  In  addition  to  the  various 
vasomotor  phenomena  that  have  been  commented  upon  there  may 
be  disturbance  of  the  rate  or  rhythm;  in  some  instances  there  is 
no  disturbance  of  the  heart  at  all,  in  others  a  simple  arrhythmia, 
in  others  a  tachycardia  or  bradycardia,  or  there  may  be  one  of  these 
latter  together  with  disturbance  of  rhythm. 

Gastro-intestinal  Tract. — A  loss  of  appetite,  nausea,  and  vomit- 
ing are  all  quite  common.  The  vomiting  is  usually  only  once  or 
twice,  usually  at  the  onset  and  after  taking  food.  Sometimes, 
however,  it  may  persist  and  be  a  very  prominent  symptom.  The 
vomiting  is  not  projectile  as  it  is  in  meningitis.     Sometimes  the 


GASTRO-TNTESTINAL  TRACT 


133 


older  patients  complain  of  gastric  or  abdominal  distress,  particu- 
larly after  taking  food,  and  there  may  be  distention  of  the  abdomen. 
Constipation  is  the  rule,  but  it  is  just  the  same  constipation,  appar- 
ently, that  is  seen  in  any  bed-ridden  patient.    Sometimes  when  there 


Fig.  47. — Patient  with  extensive  bed-sore.  Condition  on  admission  to  Children's 
Hospital  School,  Baltimore.  About  six  months  after  onset.  Patient,  aged  eight 
years. 

is  involvement  of  the  abdominal  muscles  one  feels  that  the  par- 
alysis may  be  partly  responsible.  In  some  cases  there  is  diarrhea,  but 
this  does  not  seem  to  bear  any  relation  whatever  to  the  intestinal 
lesions  as  far  as  has  been  determined  at  autopsy.     In  some  epi- 


FiG.  48. — Same  as  above. 


demies  diarrhea  may  be  a  prominent  feature.  Thus  Krause^  in  an 
epidemic  occiu-ring  in  Westphalia  reported  that  over  two-thirds  of 
the  cases  had  diarrhea. 


Deutsch.  med.  Wehnschr.,  1909,  p.  1822. 


134  SPECIAL  FEATURES  AND  SYMPTOMS 

Bed-sores. — ^The  statement  is  made  by  the  earlier  writers  that 
bed-sores  are  not  met  with,  but  one  infers  that  they  refer  more 
particularly  to  the  trophic  disturbances  so  often  seen  in  certain 
forms  of  spinal  diseases.  In  the  severely  paralyzed  cases  bed- 
sores are  not  of  uncommon  occurrence  and  the  greatest  possible 
care  should  be  taken  to  prevent  them.  The  child  should  be  kept 
scrupulously  clean;  patients  that  soil  themselves  are  perhaps  best 
treated  by  immobilizing  them  in  plaster  casts  and  placing  them 
over  a  bed-pan.  The  skin  should  be  washed  several  times  a  day 
with  alcohol,  and  this  should  be  applied  after  each  cleansing  and 
the  skin  powdered.  In  case  the  skin  is  reddened  the  application  of 
zinc  ointment  or  lanolin  will  be  found  of  very  considerable  value. 


CHAPTER    IX. 
THE  TECHNIC  OF  LUISIBAR  PUNCTURE. 

The  Position  of  the  Patient. — The  patient  may  be  either  in  a  sit- 
ting posture,  supported  by  a  nurse,  or  he  may  be  lying  on  the  side. 
Everything  else  being  equal,  we  prefer  the  latter  position,  inasmuch 
as  syncope  is  less  frequent  and  it  is  much  easier  to  control  the 
patient.  The  head  and  shoulders  should  be  bent  forward  on  the 
chest  and  the  knees  drawn  up  to  the  abdomen  so  that  the  spine 
will  be  bowed.  It  is  a  great  mistake  to  attempt  the  lumbar  puncture 
without  sufficient  assistance.  Very  young  babies  may  be  held  by 
one  nurse.  For  larger  children  two  people  are  necessary,  as  it  is 
very  difficult  to  make  the  proper  puncture  unless  the  child  is  held 
perfectly  still.  Another  person  to  hold  the  tubes  in  which  the 
fluid  is  collected  is  advisable,  though  not  necessary.  A  general 
anesthetic  is  seldom  needed,  although  occasionally  in  very  large, 
unmanageable  patients  this  may  be  used. 

The  puncture  itself  is  not  particularly  painful,  and  is  generally 
accomplished  without  accidents.  It  goes  without  saying  that  the 
strictest  septic  technic  possible  should  be  used.  The  hands  of  the 
operator  should  be  sterilized  and  the  needle  thoroughly  boiled. 
The  preparation  of  the  skin  over  the  limibar  region  of  the  spine 
consists  of  thoroughly  cleansing  with  alcohol,  and  after  this  is  dry, 
applying  a  thin  coat  of  tincture  of  iodin.  The  needle  should  be 
from  7  to  9  cm.  long,  ground  with  a  rather  blunt  point  and  properly 
sharpened.  The  needle  should  be  fitted  with  a  steel  obturator  that 
fits  perfectly,  and  this  should  be  ground  so  as  to  be  flush  with  the 
cutting  edge  of  the  needle.  This  is  important,  as  otherwise  a  small 
piece  of  cartilage  may  be  punched  out  and  block  the  needle,  and  so 
result  in  a  dry  tap.  The  puncture  is  usually  made  between  the 
third  and  fourth  lumbar  vertebme,  sometimes  between  the  second 
and  third.  A  line  through  the  superior  parts  of  both  iliac  crests 
will  pass  through  the  fourth  lumbar  vertebra  and  the  space  just 
above  the  line  is  to  be  chosen.  In  adults  and  older  children  it  is 
best  to  introduce  the  needle  about  1  cm.  to  the  side  of  the  midline 
of  the  spine  and  direct  the  needle  forward,  upward,  and  slightly 


136 


THE   TECHNIC  OF  LUMBAR  PUNCTURE 


inward  toward  the  midline.  This  avoids  the  strong  interspinous 
Hgament.  In  children  it  is  much  easier  to  introduce  the  needle 
in  the  midline  and  point  it  slightly  upward  so  as  to  pass  between 


Fig.  49.— Lumbar  puncture.     (Musser.) 

the  spines  of  the  vertebrae.  In  the  adult  the  needle  is  generally 
introduced  for  the  distance  of  from  6  to  7  cm.  before  the  sub- 
arachnoid space  is  reached.  In  children  the  distance,  of  course,  is 
shorter  and  in  infants  the  needle  need  only  be  introduced  from  2 


Fig.  50. — Lumljar  puncture — introducing  the  trocar.     (Musser.) 

to  3  cm.  If  in  introducing  the  needle  a  resistance  is  met  it  is  best 
to  withdraw  a  short  distance  and  introduce  again  in  a  slightly  differ- 
ent direction,  usually  downward,  as  resistance  generally  means  that 


PUNCTURE  HEADACHE  137 

the  bone  has  been  struck.  After  the  needle  has  reached  the  spinal 
canal  the  obturator  is  withdrawn  and  the  fluid  allowed  to  run  out. 
It  may  come  drop  by  drop  or  be  under  considerable  pressure  and 
run  in  a  rapid  stream.  The  fluid  should  be  collected  in  sterile  test- 
tubes,  and  it  is  better  to  use  two  or  three  tubes  in  case  one  should 
be  contaminated.  If  the  fluid  withdrawn  is  bloody  it  means  the 
needle  has  punctured  a  small  vein  and  another  puncture  should 
be  done  after  resterilization,  inasmuch  as  the  presence  of  blood 
will  interfere  with  the  cell  count.  After  the  fluid  has  been  withdrawn 
the  needle  is  removed  quickly  and  a  piece  of  sterile  gauze  placed 
over  the  puncture  and  securely  fastened  with  a  strip  of  adhesive 
plaster.  For  diagnostic  purposes  5  to  10  c.c.  will  be  found  sufli- 
cient.  In  cases  in  which  the  fluid  is  under  great  pressure  larger 
amounts  may  be  allowed  to  escape  with  a  view  of  relieving  sjonp- 
toms  caused  by  increased  pressure.  When  this  is  done  the  patient's 
pulse,  respiration,  and  general  condition  should  be  closely  watched 
and  the  withdrawal  of  the  fluid  stopped  if  there  is  any  marked  change 
for  the  worse. 

Puncture  Headache.^ — ^This  headache  sometimes  follows  lumbar 
puncture,  but  is  not  serious  and  lasts  but  a  short  time.  It  usually 
does  not  come  on  until  the  day  after  the  puncture  at  the  time  the 
patient  is  usually  allowed  to  be  up  in  case  he  is  not  afflicted  with 
the  disease.  It  may,  however,  come  on  immediately  after  the 
operation,  or  as  long  as  three  days  later.  It  is  a  diffuse  pain,  felt 
on  both  sides  and  rather  more  severe  over  the  forehead  and  some- 
what less  so  in  the  back  of  the  head.  Sometimes  it  is  worse  in  the 
occipital  region.  There  may  be  nausea  and  sometimes  even  violent 
vomiting,  together  with  dizziness,  some  mental  confusion  and  a 
feeling  of  faintness.  Exercise  increases  the  symptoms  and  lying 
flat  down  generally  relieves  it.  The  condition  lasts,  with  remissions, 
from  five  or  six  days  to  two  or  three  weeks.  In  the  persistent  cases 
the  mental  confusion  and  dizziness  may  cause  alarm.  Strauss  states 
that  if  but  a  small  amount  is  removed  and  that  slowly,  headache 
will  not  occur.  The  headache  can  usually  be  prevented  by  keep- 
ing the  patient  flat  for  three  days  or  more,  and  if  the  headache  does 
occur  it  is  best  treated  by  placing  the  patient  flat  on  his  back.  A 
tight  abdominal  compress,  which  increases  the  amount  of  cerebro- 
spinal fluid,  may  also  be  used.  Where  abnormal  conditions  exist 
and  there  is  headache  from  increased  pressure,  the  withdrawal  of 
fluid  generally  relieves  it. 

1  Dana:   Jour.  Am.  Med.  Assn.,  April  7,  1917,  p.  1017. 


138  THE  TECHNIC  OF  LUMBAR  PUNCTURE 

Normal  Cerebrospinal  Fluid. — Normal  cerebrospinal  fluid  depends 
in  amount  to  some  extent  on  the  degree  of  intracranial  pressure, 
but,  as  a  rule,  about  5  to  10  c.c.  are  withdrawn  during  lumbar 
puncture.  The  fluid  is  clear  and  colorless,  looks  like  water  and  drops 
from  the  needle  drop  by  drop.  The  specific  gravity  is  from  1.005 
to  1.013,  usually  about  1.008.  The  reaction  is  alkaline  and  the  fluid 
is  found  to  contain  water,  albumin,  fat,  cholestrin,  chlorides,  sul- 
phates, phosphates,  and  alcoholic  extracts.  In  addition  to  this  there 
is  present  a  small  amount  of  urea  and  a  trace  of  cholin.  The  sugar 
content  of  normal  spinal  fluid  is  present  as  glucose,  from  0.06  to 
0.09  per  cent.  Serum-albumin  or  serum-globulin  and  a  trace  of 
albumose  bodies  are  also  present.  The  freezing-point  of  normal 
spinal  fluid  is  similar  to  the  freezing-point  of  blood,  about 
-0.56°  C. 

Cytology. — A  few  endothelial  cells  may  be  seen  and  an  occasional 
lymphocyte  is  present,  otherwise  no  cells  at  all. 

Bacteriology. — As  far  as  the  presence  of  organisms  are  concerned, 
one  can  say  with  safety  that  in  normal  spinal  fluid  no  organisms 
are  present. 

Cell  Counts  of  Cerebrospinal  Fluid. — For  diagnostic  purposes  both 
the  number  of  cells  present  and  the  character  are  important. 

The  Differential  Count. — This  is  best  made  by  pouring  2  or  3 
c.c.  of  the  spinal  fluid  into  a  conical  test-tube  and  centrifugalizing 
for  40  to  50  minutes.  The  supernatant  fluid  is  poured  off  and  the 
sediment  in  the  bottom  of  the  tube  taken  up  with  a  capillary  pipet. 
By  blowing  the  sediment  gently  back  from  the  pipet  into  the  test- 
tube  several  times,  the  cells  are  thoroughly  mixed  and  a  more 
accurate  count  can  be  made.  A  small  drop  of  the  sediment  is  then 
placed  on  a  glass  slide,  spread  out  and  allowed  to  dry  in  the  air. 
It  is  then  passed  through  the  flame  to  fix  it  and  stained.  Wilson's, 
Jenner's,  Giemsa's,  or  Hastings'  stain  may  be  used.  Our  own 
preference  is  for  Wilson's  stain,  which  after  a  little  practice  gives 
most  satisfactory  specimens.  About  300  cells  should  be  counted 
throughout  the  slide  in  order  to  arrive  at  a  reliable  estimate.  Very 
expert  laboratory  workers  may  make  the  count  with  a  low  power. 
Those  less  expert  will  use  a  magnification  of  about  300,  that  is, 
about  a  number  I  eye-piece  and  a  one-sixth  objective. 

The  Total  Count. — This  is  made  by  exactly  the  same  technic  as 
is  used  in  a  total  white  count  of  the  blood.  The  Fuchs-Rosenthal 
counter  is  generally  preferred.  A  staining  fluid  is  made  up  of 
methyl  violet,  0.1;  glacial  acetic  acid,  2;  water,  50.     A  special 


THE  CHEMICAL   TESTS  '  139 

counting  chamber  is  designed  for  counting  the  cells  of  the  spinal 
fluid.  Using  the  white  cell  pipet  the  staining  fluid  is  drawn  to  the 
mark  I,  the  spinal  fluid  to  mark  XL  All  the  cells  in  the  entire 
ruled  area  are  counted  and  the  total  number  divided  by  3  gives 
the  number  of  cells  per  cubic  millimeter. 

The  Chemical  Tests. — Tests  may  be  made  for  globulin,  albumin, 
and  the  reduction  of  Fehling's  solution. 

The  Glohulin  Test. — Pandy's  test  will  be  found  easy  and  reliable. 
The  reagent  consists  of  a  saturated  solution  of  phenol  (carbolic  acid), 
which  is  made  by  taking  100  parts  of  the  pure  crystals,  and  adding 
100  parts  of  hot  distilled  water.  This  mixture  should  be  kept  at 
room  temperature  for  a  period  of  three  or  four  days  and  during  this 
time  it  should  be  shaken  rather  frequently.  The  clear  supernatant 
fluid  is  then  drawn  off  and  is  ready  for  use.  In  order  to  make  the 
test  1  or  more  c.c.  of  the  reagent  is  poured  into  the  test-tube  and 
one  drop  of  the  spinal  fluid  then  added.  Under  normal  conditions 
no  change  occurs  when  the  spinal  fluid  is  added.  If,  however,  the 
protein  content  of  the  spinal  fluid  should  be  increased  a  bluish-white 
cloud  is  seen  at  the  point  of  contact.  This  resembles  somewhat  a 
ring  of  smoke  and  after  a  short  space  of  time  settles  to  the  bottom. 
The  intensity  of  the  reaction  is  judged  by  the  density  of  this  bluish- 
white  cloud  and  varies  directly  with  the  amount  of  globulin  present. 
This  is  usually  recorded  as  with  a  cipher  for  negative  reactions  and 
by  plus  marks,  varying  from  one  to  four,  for  positive  reactions, 
according  to  the  intensity. 

The  Test  for  Albumin. — This  may  be  made  by  the  nitric  acid 
test  or  by  the  heat  and  acetic  acid  test,  or  the  total  protein  may  be 
more  accurately  judged  by  the  Kjeldahl  method.  The  total  protein 
may  be  approximately  estimated  by  Tsuchiga's  modification  of 
Esbach's  method. 

Tsuchiya's Modification. — ^The  reagent  consists  of  phosphotungstic 
acid,  1.5  grams,  concentrated  hydrochloric  acid,  5  c.c,  ethyl  alcohol, 
95  c.c.  Special  albuminometer  tubes  are  employed  which  bear  two 
marks,  One  U,  indicating  the  point  to  which  the  urine  must  be 
added,  and  the  other  point  R,  the  point  to  which  the  reagent  is 
added.  The  lower  portion  of  the  tube  up  to  U,  bears  a  scale  which 
reads  from  1  to  7,  corresponding  to  the  amount  of  albumin  per  1000. 
The  tube  is  filled  to  U  with  the  spinal  fluid,  the  reagent  then  added 
to  the  point  R.  The  tube  is  closed  with  a  stopper,  inverted  twelve 
times,  and  then  set  aside  for  twenty-four  hours.  At  the  expiration 
of  that  time  the  amount  per  1000  in  grams  can  be  read  (milligrams). 


140  THE   TECH  NIC  OF  LUMBAR  PUNCTURE 

The  Colloidal  Gold  Reaction  and  the  Cerebrospinal  Fluid.— After 
studying  the  cases  in  a  small  epidemic  occurring  in  Baltimore  in 
1916,  Felton  and  Maxcy,^  have  given  the  results  of  their  studies  in 
reference  to  the  reactions  with  Lange's  colloidal  gold  test.  This 
test  was  carried  out  according  to  the  method  advised  by  Miller, 
Brush,  Hammers  and  Felton,^  whose  article  should  be  consulted  by 
those  unfamiliar  with  the  reaction.  They  suggest  that  the  different 
reactions  be  classified  as  occurring  in  zone  1  (paretic  zone) ,  maximum 
precipitation  from  1  to  10  to  1  to  160,  with  complete  decolorization; 
zone  2  (luetic) ,  maximum  precipitation  from  1  to  40  to  1  to  160,  with 
decolorization  up  to  4  (light  blue);  zone  3  (meningitic) ,  maximum 
precipitation  beyond  1  to  160,  producing  a  maximum  decolorization 
of  3  (blue) .  In  the  acute  stage  the  fluid  reacts  in  dilutions  of  from 
1  to  40  and  from  1  to  160.  Later  on  in  the  disease,  in  the  second  and 
third  weeks,  the  reaction  either  remains  the  same  or  there  is  a 
tendency  to  clear  up  in  some  cases,  while  in  others  there  is  precipi- 
tation in  higher  dilutions.  During  this  period  there  is  no  constant 
rule.  In  the  fourth  to^  the  eighth  weeks  the  reaction  runs  prac- 
tically parallel  to  the  globulin-albumin  content  and  still  occurs  in 
dilutions  of  1  to  40  and  1  to  160.  The  authors  suggest  that  inas- 
much as  the  reactions  occur  constantly  in  the  same  zone  that  they 
may  be  of  help  in  making  a  diagnosis  in  poliomyelitis. 

Macroscopic  Appearance  of  the  Cerebrospinal  Fluid  in  Poliomyelitis. — 
Great  care  should  be  taken  to  avoid  contamination  of  blood,  and  a 
No.  18  gauge  needle,  not  over  three  inches  long,  will  be  found  best 
suited  for  withdrawing  the  fluid  for  diagnostic  purposes.  If  blood  is 
withdrawn  in  the  fluid  it  cannot  be  used  for  accurate  diagnostic 
tests.  If  but  little  blood  is  present  it  will  not  cause  any  macroscopic 
changes,  or  if  a  slight  amount  is  present  produces  a  yellowish 
shimmer  and  an  opalescence  of  the  fluid.  At  the  bedside  the  fluid 
is  apparently  clear  in  most  cases,  but  if  it  is  examined  in  a  dark  room 
with  the  test-tube  illuminated  by  transmitted  light,  it  will  be  seen 
to  have  a  ground-glass  appearance  due  to  the  increased  number  of 
lymphocytes.  The  use  of  a  magnifying  glass  helps  in  this  test,  in 
some  instances ;  the  particles  in  the  fluid  can  be  seen  moving  about 
and  can  be  set  in  motion  by  slightly  agitating  the  fluid.  If  the  fluid 
is  allowed  to  stand  the  cells  sink  to  the  bottom  and  the  supernatant 
fluid  is  clear,  but  the  ground-glass  appearance  can  again  be  repro- 
duced by  shaking.    This  appearance  of  the  fluid  often  saves  time  in 

1  Jour.  Am.  Med.  Assn.,  March  10,  1917,  p.  752. 

2  Bull.  Johns  Hopkins  Hosp.,  1915,  p.  391. 


CEREBROSPINAL  FLUID  IN  POLIOMYELITIS  141 

treatment  of  cases  when  serum  is  to  be  used,  if  meningitis  can  be 
excluded.  The  microscopic  examination  should  always  be  under- 
taken later  to  avoid  mistaking  red  blood  cells  for  lymphocytes. 
Similar  fluids  may  be  found  in  cerebrospinal  fever  and  other  forms 
of  meningitis. 

The  Foam  Test. — This  is  made  by  filling  a  test-tube  half-full 
with  the  fluid  and  shaking  very  thoroughly.  The  presence  of  blood 
vitiates  the  test,  which  depends  on  the  increased  amount  of  albumin 
and  globulin  in  the  fluid  in  poliomyelitis.  The  shaking  produces  a 
foam  which  lasts  from  a  half-hour  to  an  hour  or  longer.  It  is  much 
more  dense  and  finer,  and  much  greater  in  volume  and  more  per- 
sistent than  that  produced  by  shaking  a  normal  fluid.  This  is  not 
supposed  to  take  the  place  of  the  other  tests,  but  helps  in  forming  a 
judgment  at  the  bedside  before  the  fluid  can  be  examined  by  the 
other  methods. 

The  Cerebrospinal  Fluid  in  Poliomyelitis. — The  cerebrospinal  fluid 
in  practically  all,  if  not  all,  of  the  cases  which  show^  nervous 
S}Tnptoms,  is  abnormal,  and  may  present  a  number  of  different 
changes,  which,  in  the  main,  are  constant.  The  fluid  is  sterile, 
usually  clear,  and  sometimes  a  slight  fibrin  web  forms  in  it.  In 
exceptional  cases  the  fluid  may  be  cloudy  or  even  bloody.  Usually, 
the  presence  of  blood  means  a  faulty  technic,  the  error  generally 
being  the  use  of  a  needle  without  a  sufficiently  close-fitting  obturator. 
The  number  of  cells  is  definitely  increased.  The  normal  fluid  con- 
tains from  five  to  ten  cells  per  cubic  millimeter,  while  in  polio- 
myelitis the  number  of  cells  is  increased  from  sixteen  to  twenty  to 
one  hundred,  but  in  some  instances  this  number  is  greatly  exceeded, 
as  high  as  five  hundred  or  over  being  met  with.  In  the  early  stage 
of  the  disease,  before  the  paralysis  has  made  its  appearance,  the  chief 
t}T)e  of  cell  found  is  the  pohTnorphonuclear.  Sometimes  they  form 
from  SO  to  90  per  cent,  of  the  cells  present.  After  the  appearance 
of  the  paralysis,  the  cells  found  are  chiefly  lymphocytes  and  from  75 
to  100  per  cent,  of  the  cells  present  are  that  of  the  mononuclear 
type.  There  are  also  present  large  mononuclear  cells  of  an  endo- 
thelial type  which  have  been  regarded  by  DuBois  and  Xeal,^  as 
rather  characteristic  of  poliomyelitis.  There  are  also  phagocytic 
cells  present.  It  must  be  borne  in  mind  that  even  a  slight  admixture 
of  blood  in  the  fluid  will  account  for  a  certain  number  of  polynuclear 
cells.    The  cells  rapidly  disappear  from  the  cerebrospinal  fluid,  so 

'  American  Journal  of  Diseases  of  Children,  January,  1915. 


142 


THE  TECHNIC  OF  LUMBAR  PUNCTURE 


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CEREBROSPINAL  FLUID  IN  POLIOMYELITIS  143 

that  after  the  first  two  weeks  the  count  is  either  normal  or  nearly  so. 
The  fluid  is  sterile,  gives  a  positive  Fehling's  reaction  like  the  normal 
fluid,  and  usualh'  contains  a  very  definite  reaction  for  globulin,  which 
is,  however,  not  as  pronounced  as  that  found  in  the  various  forms 
of  meningitis.  During  the  first  week,  globulin  is  found  in  perhaps 
one-half  of  the  fluids  examined.  The  globulin  increases,  as  a  rule, 
until  about  the  third  week,  when  it  decreases,  but  a  slight  increase 
may  be  detected  even  after  seven  weeks  or  longer.  The  reaction 
to  Fehling's  solution  is  of  slight  value  in  diagnosis,  inasmuch  as  in 
tuberculous  meningitis,  and  sometimes  in  meningitis  due  to  other 
organisms,  this  power  to  reduce  Fehling's  solution  is  absent.  If 
the  reaction  is  present  it  means  nothing;  if  it  is  absent  it  is  a 
point  against  poliomyelitis. 

We  should  also  call  attention  to  the  fact  that  in  certain  cases  of 
meningismus  the  fluid  may  be  cloudy.  These  are  cases  in  which 
there  have  been  prolonged  convulsions,  cases  of  whooping-cough 
with  very  severe  and  frequent  paroxysms,  and  fluids  removed  just 
before  death.  All  of  these  fluids  show  an  increase  in  the  cells,  and 
globulin  or  albumin  is  present,  or  both.  In  the  case  of  convulsions 
the  changes  are  probably  due  to  the  edema  produced  and  in  whoop- 
ing-cough they  have  been  attributed  to  minute  hemorrhages,  whereas 
those  coming  on  just  before  death  are  probably  due  to  changes  in  the 
circulation. 

The  fluid  from  sj^jhilitic  meningitis  may  be  hemorrhagic  and  in 
this  case  all  of  the  successive  tubes  used  to  collect  the  fluid  show  the 
same  appearance,  whereas  when  a  vein  has  been  punctured  the  first 
tubes  show  more  blood  than  the  later  ones.  The  fluid  may  be 
yellow  and  coagulate  spontaneously  and  the  so-called  reaction  of 
Froin,  and  this  may  also  occur  in  other  fluids. 

Chemical  studies  of  fluids  have  yielded  very  little  result.  Various 
studies  have  been  made  by  observers  in  New  York  on  the  total 
nitrogen,  the  amount  of  protein  nitrogen,  creatine  and  ammonia 
nitrogen,  but  information  obtained  by  a  study  of  these  various 
constituents  of  fluid  is  very  slight. 


CHAPTER  X. 
DIAGNOSIS. 

The  diagnosis  of  the  disease  presents  certain  difficulties,  the 
commonest  of  which  are  in  the  cases  seen  in  the  preparalytic  stage. 
If  it  is  borne  in  mind  that  the  disease  is  to  be  regarded  as  a  general 
infection  and  that  various  parts  of  the  body  may  be  affected,  one 
understands  more  readily  the  rather  protean  symptomatology  of 
the  disease.  A  careful  study  of  the  sjonptomatology  of  the  pre- 
paralytic stage  is  important,  and  during  an  epidemic  in  all  cases 
in  which  the  disease  is  suspected  a  lumbar  puncture  should  be  made. 

The  question  of  whether  the  child  may  have  poliomyelitis  with- 
out having  any  changes  in  the  cerebrospinal  fluid  is,  at  present,  an 
open  one.  The  general  rule  is  that  if  a  case  shows  a  normal  spinal 
fluid  it  is  not  to  be  regarded  as  poliomyelitis.  Usually  where  there 
have  been  any  symptoms  whatever  of  involvement  of  the  nervous 
system  the  cerebrospinal  fluid  shows  changes  and  the  case  turns 
out  to  be  one  of  poliomyelitis.  One  sees  cases  occasionally  associated 
with  other  cases  in  the  same  family,  in  which  the  cerebrospinal  fluid 
is  normal,  but  in  which  the  patient  is  strongly  suspected  of  having 
the  disease.  This  point  might  possibly  be  cleared  up  by  a  series 
of  observations  upon  animals.  With  the  better  understanding  of 
the  preparalytic  stage  and  the  cases  which  do  not  go  on  to  paraly- 
sis, we  feel  sure  that  larger  numbers  of  patients  will  be  found  who 
come  under  this  class,  and  there  is  great  need  for  some  simple  posi- 
tive means  of  differentiating  poliomyelitis  from  other  diseases.  So 
far  as  we  know  skin  tests  have  not  been  studied,  but  it  would  seem 
that  this  field  might  yield  something  of  value. 

Immunity  Test. — Another  method  of  diagnosis  which  has  been 
employed,  but  which  is  not  suited  for  ordinary  use,  is  to  take  the 
serum  from  the  suspected  patient,  mix  it  with  a  fatal  dose  of  the 
virus,  and  after  incubating  it  inject  it  intracerebral] y  into  monkeys. 
Failure  to  develop  the  disease  would  indicate  that  the  virus  had 
been  neutralized,  but  it  must  be  borne  in  mind  that  serum  from 
persons  having  had  the  disease  might  also  neutralize  the  fluid,  and 
if  the  individual  had  passed  through  an  unrecognized  abortive 
attack  the  results  could  well  be  misleading. 

Other  Diagnostic  Features. — Another  feature  in  the  diagnosis  is 
to  determine  whether  or  not  there  is  involvement  of  the  nervous 


DIAGNOSIS  145 

system,  and  all  signs  of  meningeal  irritation  should  be  carefully 
studied.  These  have  been  considered  in  the  symptomatology  of 
the  disease,  and  one  should  always  study  the  intracranial  pressure 
if  the  fontanelle  is  open,  and  also  Brudzinski's  leg  and  his  head  sign 
as  well,  Kernig's  sign,  and  the  others  which  it  is  not  necessary  to 
repeat  at  this  place.  Later  the  question  of  presence  or  absence  of 
paralysis  must  be  decided,  and  this  at  times,  may  be  an  exceedingly 
difficult  point,  particularly  in  young  or  very  ill  children.  This  has 
been  considered  in  the  section  on  Paralysis,  to  which  the  reader  is 
referred;  but  we  might  call  attention  to  one  point  which  has  not  been 
decided,  and  that  is  the  shortest  length  of  time  that  the  paralysis 
may  exist  in  poliomyelitis.  We  are  of  the  opinion  that  loss  of  power 
may  be  exceedingly  transitory  and  may  last  only  a  day  or  two  or 
three.  The  opinion  of  some  other  observers,  however,  is  that  the 
impahment  of  motion  from  poliomyelitis  persists  at  least  a  week. 

No  illness 96 

Hysteria 2 

Uremia  and  nepliritis 1 

Tuberculous  meningitis      .  8 

Rachitic  pseudoparalysis 

Pulmonary  tuberculosis 

Purulent  pleurisy 

Tetany 

Gastro-enteritis  and  meuingismus 

Cerebral  thrombosis 

Epilepsy  and  arthritis 

JNIentally  defective  (idiocy) 

Streptococcus  meningitis 

Piu-ulent  peritonitis 

Intussusception  (?) ;  gastro-enteritis 

Dentition 

Congenital  calcaneovalgus 

Bronchopneumonia;  pertussis 

Cervical  adenitis  and  cellulitis 

Bronchopneumonia 

Diphtheritic  paralysis 

Malnutrition  and  spasmopliilia 

Seven-5'ear-old  case  of  infantile  paralysis 

Pericarditis 

Kyphosis  (Pott's  disease) 

Cerebrospinal  meningitis 

Hemiplegia  and  syphilitic  endarteritis 

Transverse  myelitis  specific  (?) 

Infiuenza  meningitis 

Pneumococcus  meningitis 

Cerebral  arteriosclerosis  with  traumatic  neuritis  of  supra-orbital  nerve 

Spastic  paralj"sis  (congenital  tetanoid  pseudoparaplegia) 

Choi-ea 

Bell's  palsy 

Septic  arthritis 

Hemiplegia,  cerebral  hemorrhage 

Measles 

10 


146  DIAGNOSIS 

The  Accuracy  of  Diagnosis. — ^As  to  the  accuracy  of  diagnosis,  the 
observers  of  the  New  York  Health  Department  beheve  that  in 
private  practice  there  are  about  4  per  cent,  of  errors  made.  In  the 
cases  which  the  department  studied  in  the  epidemic  of  1916  the 
total  error  was  2.65.  Some  idea  of  what  may  be  mistaken  for  polio- 
myelitis may  be  gained  by  a  study  of  the  accompanying  list  of 
diseases  with  which  patients  were  found  to  be  suffering  after 
admission  to  the  hospitals  under  the  care  of  the  New  York  City 
Health  Department.  All  of  these  patients  were  primarily  admitted 
as  supposed  poliomyelitis  cases. 

Differential  Diagnosis. — The  following  points  will  be  found  of 
interest  in  the  differential  diagnosis  of  the  disease.  These  obser- 
vations might  be  extended  very  largely,  but  anyone  with  a  clinical 
experience  will  find  the  points,  given  quite  suJBEicient. 

One  of  the  most  important  things  at  the  outset  is  to  exclude 
surgical  things,  such  as  sprains  and  fractures,  and  there  are  a  num- 
ber of  instances  on  record  in  which  a  child  suddenly  lost  the  use 
of  an  arm  or  leg  and  a  diagnosis  of  poliomyelitis  was  made,  and  it 
was  subsequently  discovered  that  the  loss  of  power  was  due  to  a 
fracture  or  a  sprain. 

One  should  also  remember  that  patients  with  other  diseases, 
surgical  or  otherwise,  may  have  poliomyelitis  as  a  secondary  infec- 
tion, and  these  cases  may  be  exceedingly  puzzling.  We  know  of 
one  instance  in  which  a  boy  with  a  fractured  arm  was  taken  with 
very  severe  pains  some  two  weeks  after  the  injury,  and  it  was  sub- 
sequently found  that  he  was  suffering  with  acute  poliomyelitis,  and 
the  pains  had  no  relation  whatever  to  the  injury. 

Still  another  condition  which  may  cause  an  incorrect  diagnosis 
to  be  made  is  the  loss  of  power  which  comes  from  pressure  on  a 
nerve.  The  pressure  may  not  have  been  maintained  long  enough 
to  produce  an  actual  paralysis,  and  yet  there  is  a  definite  loss  of 
power  from  a  few  minutes  to  a  few  hours.  Falling  asleep  with  the 
arm  over  the  side  of  a  chair  or  over  the  side  of  the  bed  is  the  com- 
monest cause;  one  leg  hanging  over  the  edge  of  the  bed,  or  the  child's 
lying  on  some  hard  object  and  falling  asleep  may  also  occasionally 
be  the  history  given  in  these  cases.  There  is  usually  the  sensation 
of  numbness  or  tingling  in  addition  if  the  child  is  old  enough  to 
describe  its  symptoms. 

In  all  cases  in  which  there  is  a  question  about  the  loss  of  power 
the  diagnosis  should  be  withheld  until  the  child  can  be  seen  on  a 
subsequent  day.    This  procedure  will  save  many  embarrassments. 


SCURVY  147 

There  are  few  diseases  in  which  the  physician  may  be  so  urgently 
pressed  to  say  definitely  whether  the  child  is  affected  or  not. 

Croup  or  Laryngitis. — With  a  paralysis  of  the  laryngeal  muscles 
the  case  may  present  such  dyspnea  as  to  require  intubation  and  the 
child  may  be  suspected  of  having  croup,  laryngitis,  or  laryngeal 
diphtheria.  Other  paralyses  will  generally  be  found  on  careful 
examination,  and  the  absence  of  any  other  evidence  of  diphtheria 
will  generally  make  the  case  clear. 

Bronchopneumonia. — A  child  with  a  paralysis  of  the  respiratory 
muscles  may  suggest  a  pneiunonia.  On  careful  examination  either 
the  thoracic  muscles  or  the  diaphragm  will  be  found  paralyzed. 
The  fixed  chest  wall,  either  one  or  both  sides  with  exaggerated 
abdominal  breathing,  characterizes  the  first.  When  the  diaphragm 
is  paralyzed,  instead  of  inspiratory  distention  of  the  abdomen  there 
is  an  inspiratory  retraction.  With  hurried  respiration  and  a  little 
bronchitis  or  pulmonary  edema  the  physical  signs  may  be  mis- 
leading unless  one  is  unusually  skilled. 

Nephritis  with  Uremia. — This  may  be  misleading  on  account  of 
the  convulsions  or  coma.  The  edema  and  lu-inary  findings  will  be 
sufficient  to  clear  up  the  diagnosis,  or  a  Imnbar  puncture  may  be 
done. 

Acidosis. — Cyclic  Vomitmg. — This  may  be  very  misleading.  The 
profound  languor  may  suggest  a  generalized  slight  loss  of  power, 
such  as  is  sometimes  seen.  There  may  be  twitching  of  the  muscles 
and  other  nervous  symptoms.  The  acetone  odor  of  the  breath 
and  the  marked  diacetic  reaction  in  the  urine  will  point  the  way. 
The  reaction  in  ordinary  febrile  distiu"bances  is  rarely  as  pronounced 
as  in  acidosis.    A  lumbar  puncture  may  be  needed. 

Diarrhea. — ^Mien  the  s^Tiiptoms  of  gastro-intestinal  disturbances 
are  very  marked  the  diagnosis  may  not  even  be  suspected,  inas- 
much as  meningismus  and  other  nervous  symptoms  are  not  uncom- 
mon in  connection  with  diarrhea.  The  lumbar  puncture  will  afford 
a  means  of  settling  the  question  in  suspected  cases. 

A  second  class  of  disease  in  which  there  is  pseudoparalysis  or 
spasm  may  also  cause  difficulty  in  diagnosis.  This  includes  scurvy, 
rickets,  hysteria,  the  spasmophilia  seen  in  nutritional  disturbances, 
and  tetany. 

Scurvy. — In  severe  scurvy  the  child  assumes  a  position  which 
suggests  poliomyelitis.  The  paralysis  is  only  apparent  and  the 
child  can  be  made  to  move  the  extremities  if  sufficientlv  irritated. 


148  DIAGNOSIS 

In  the  very  late  cases  the  muscles  will  be  seen  to  move  if  the  limbs 
do  not.  The  reflexes  are  normal.  There  are,  in  addition,  the  classic 
signs,  the  bleeding  of  the  gums,  the  submucous  and  subdermal 
hemorrhages,  the  periosteal  swellings,  etc.,  and  symptoms  rapidly 
disappear  on  the  administration  of  orange  juice. 

Rickets. — In  acute  rickets  there  is  a  pseudoparalysis  like  that 
described  in  scurvy,  but  in  place  of  the  scorbutic  symptoms  there 
are  marked  evidences  of  rickets. 

Tetany. — The  characteristic  position,  the  spasm  being  chiefly  in 
the  hands  and  feet  and  bilateral,  the  exaggerated  reflexes,  the  con- 
traction of  the  muscles  on  percussing  the  nerve,  best  seen  in  the 
facial,  and  the  spasm  caused  by  constricting  a  limb,  make  the 
diagnosis  easy. 

Spasmophilia. — Apart  from  tetany  a  definite  tendency  to  contrac- 
tion of  the  muscles  exists  in  certain  poorly  nourished  young  infants. 
The  reflexes  are  increased  and  the  stiffness  of  the  muscles  is  general. 

Hysteria. — This  may  present  some  real  difficulties.  Fortunately 
it  is  rare  in  older  and  practically  absent  in  young  children.  The 
reflexes  are  normal  and  there  are  sensory  disturbances,  usually 
anesthesia  of  the  glove  and  stocking  type.  If  the  condition  has 
existed  for  some  time  the  absence  of  marked  atrophy  is  of  value. 

The  third  class  of  cases  includes  those  in  which  there  is  some 
definite  disease  of  the  nervous  system.  To  avoid  repetition  let  us 
insist  wpon  the  necessity  of  obtaining  the  history  of  the  attack.  This 
will  save  many  embarrassments  and  will  also  eliminate  the  congenital 
conditions.  The  history  may  be  impossible  or  difficult  to  get  or 
may  be  misleading,  but  usually  it  will  help  tremendously. 

In  this  connection  one  must  bear  in  mind  the  possibility  of  encoun- 
tering an  old  poliomyelitis  with  some  intercurrent  fever  added. 
We  are  dealing  only  with  the  diagnosis  in  the  acute  stage  or  near 
it,  so  that  the  differential  diagnosis  between  the  old  nervous  lesions 
will  not  be  touched  on. 

,  In  the  following  diseases  the  examination  of  the  cerebrospinal  fluid 
is  the  deciding  point: 

Tuberculous  Meningitis. — This  may  give  more  difficulty  than  any 
other  condition.  The  general  appearance,  as  a  rule,  is  different, 
but  this  may  not  mean  much  until  the  child  has  been  seen  several 
times.  The  cerebrospinal  fluid  is  under  greater  pressure  than  in 
poliomyelitis.  Sooner  or  later  there  are  changes  in  the  eye-grounds. 
The  onset  is  more  slow  and  more  irregular.    The  dominant  symp- 


CEREBRAL   THROMBOSIS  149 

toms  are  drowsiness,  vomiting,  irregular  pulse  and  respiration,  con- 
vulsions, and  rigidity  of  the  muscles.  The  reflexes  are  increased. 
In  poliomyelitis  the  length  of  time  to  reach  the  same  stage  is  much 
more  brief,  and  while  in  the  preparalytic  stage  there  may  be  rigidity 
or  increased  reflexes,  the  tendency  is  to  become  flaccid  and  to  have 
a  loss  of  reflexes. 

Cerebrospinal  Fever. — kt  the  onset  the  two  diseases  may  be  strik- 
ingly alike.  The  sudden  onset  wdth  vomiting  and  high  fever,  the 
prostration  and  rigidity  of  neck  and  extremities,  the  drowsiness 
with  irritability  and  hyperesthesia,  may  be  simulated  by  polio- 
myelitis. The  petechial  eruption,  if  present,  is  a  help,  and  after  a 
few  days  the  marked  spasticity  and  increased  reflexes  give  a  picture 
usually  easy  to  distinguish. 

Acute  Syphilitic  Meningitis. — This  may  present  considerable  diffi- 
culties, inasmuch  as  the  cerebrospinal  fluids  may  be  much  alike. 
There  is  usually  an  optic  neuritis,  involvement  of  the  extrinsic 
ocular  nerves,  and  a  little  later  there  may  be  other  paralyses,  such 
as  a  hemiplegia.  The  onset  is  almost  always  gradual,  usually  tak- 
ing a  month  to  six  weeks  to  a  full  development,  and  during  this 
time  the  patient  is  exceedingly  nervous,  subject  to  vertigo  and 
sudden  vomiting  attacks  without  nausea  and  sometimes  marked 
polyuria,  occasionally  convulsions  and  sometimes  ataxia.  In  some 
instances  the  onset  may  be  rather  rapid,  and  in  case  of  doubt  a 
Wassermann  should  be  made.  Noguchi's  butyric  acid  reaction 
may  be  of  some  value,  as  is  also  the  colloidal  gold  reaction. 

Other  Forms  of  Meningitis. — Much  as  above,  the  diagnosis  depend- 
ing on  finding  the  causal  organisms  in  the  cerebrospinal  fluid. 

Meningismus. — Meningeal  symptoms,  drowsiness,  retraction  of 
the  head,  etc.,  may  be  seen  in  connection  with  inflammatory  dis- 
eases of  the  body  elsewhere,  as  in  pneumonia  and  enterocolitis. 
This  may  be  intensified  by  a  great  loss  of  fluid  from  the  body,  as 
in  the  last-named  disease.  These  conditions  may  tax  the  diagnostic 
powers  if  only  the  symptoms  and  physical  signs  are  depended  upon. 
The  recognition  of  the  existing  disease  and  the  cerebrospinal  fluid 
clear  up  any  doubts. 

Cerebral  Thrombosis. — This  is  seen  in  connection  with  inflamma- 
tory diseases  elsewhere  in  the  body^  and  the  diagnosis  may  not  be 
suspected.  If  symptoms  are  produced  that  stand  out  above  those 
of  the  causative  condition  they  are  convulsions  and  paralysis,  eith.ir 
localized  or  general,  strabismus  and  coma.  When  the  disease  extends 
from  a  neighboring  inflammation,  as  in  the  nose  or  ear,  the  symp- 


150  blAGNOBiS 

toms  may  be  more  marked,  and  consist  of  headache,  drowsiness, 
and  if  pyemia  occurs,  chills,  sweats,  and  a  high  variable  temperature. 
We  have  seen  one  instance  of  a  lateral  sinus  thrombosis  in  which 
the  drowsiness  and  irritability  were  not  unsuggestive  of  poliomye- 
litis. The  localizing  symptoms,  cyanosis  of  the  face  with  dilatation 
of  the  temporal  and  frontal  veins  in  thrombosis  of  the  longitudinal 
sinus,  the  marked  edema  of  eyelids  and  face  and  protrusion  of  the 
eye  in  cavernous  thrombosis,  and  the  extension  into  the  neck  in 
lateral  sinus  trouble,  soon  make  the  diagnosis  plain. 

Mental  Deficiency. — When  there  is  some  febrile  disturbance  this 
has  more  than  once  been  mistaken  for  poliomyelitis.  The  history, 
if  obtainable,  and  the  subsequent  history,  if  not,  will  generally 
make  the  question  clear,  and  one  can  always  resort  to  a  lumbar 
puncture.  We  have  seen  some  extraordinary  clinical  pictures 
when  the  two  were  associated. 

Amaurotic  Family  Idiocy. —  Tay-Sach's  Disease. — This,  too,  can 
be  mistaken  if  there  is  an  intercurrent  fever,  as  the  flaccidity  sug- 
gests poliomyelitis.  The  condition  affects  all  the  muscles,  the 
blindness  is  apparent,  and  there  are  characteristic  changes  in  the 
eye-grounds.  It  occurs  in  Jews,  and  the  history  of  gradual  onset, 
beginning  between  the  third  and  sixth  month,  is  usually  obtainable. 

Transverse  Myelitis. — ^This  may  occur  in  connection  with  the  acute 
infectious  diseases.  The  increased  reflexes  below  the  lesion  and  the 
involvement  of  bladder  and  bowels  ought  to  make  the  diagnosis 
easy. 

Pott's  Disease. — By  pressure  this  may  cause  a  paralysis  with 
increased  reflexes.  The  diagnosis  is  usually  apparent,  but  cases 
have  been  sent  to  hospitals  as  poliomyelitis. 

Congenital  Spastic  Paralysis. — Despite  the  fact  that  these  do  not 
resemble  acute  poliomyelitis,  they  have  been  mistaken  for  it.  The 
differential  diagnosis  of  late  poliomyelitis  and  these  cases  is  another 
story. 

Chorea. — This  disease  has  also  been  mistaken  for  poliomyelitis, 
but  ordinary  careful  examination  ought  to  solve  the  difficulty. 

Facial  Paralysis. — BelVs  Palsy. — In  times  of  epidemic  this  may 
give  considerable  difficulty.  In  doubtful  cases  the  only  way  to 
clear  up  the  diagnosis  is  by  lumbar  puncture,  but  a  facial  paralysis 
coming  on  after  definite  exposure  to  cold  and  preceded  by  earache 
is  apt  to  be  called  Bell's  palsy,  and  the  same  is  true  of  cases  in 
which  there  is  marked  involvement  of  the  ear.    On  the  other  hand. 


PERIPHERAL  NEURITIS 


151 


a  case  coming  on  with  a  history  simihir  to  poHomyelitis  can  fairly 
safely  be  classed  as  that  disease.  (See  also  Paralysis  of  the  Seventh 
Nerve.) 

Peripheral  Neuritis. — Cases  of  this  disease  may  cause  very  dis- 
tinct difficulties  in  diagnosis.  In  children  it  usually  follows  an 
infectious  disease.    It  is  most  common  after  diphtheria,  and  there 


Frontalis 

Corrug.  S!(perci7.-4— ^^^i^^^j^.^ 
Orbicid.  palpebrae-/^    t>>^  ®J 

Kasal^;^-' 

Zygomatic  Majr—J* 

Minr- 
Orbiciilaris  ovisac" 


Levator  menti-- — A 

Quadrat-  menti 

Triangular,  menti- 


Platysni,  viyoiqes* 

N.  Phrenic 

I  1 

point 

N".:  Thoracic  ant.  g. 


Siemo-cleidoJ)>mstoid  6 
®  N.  Accessor Lus  7 

•  Trlipe'gmsS 
EEB'S  ^^\  fj 

\®  N,AxllJaris  9 

®JV.  Thoracic  long.  10 
tPZca;.  Brachial.  11 


Fig.  51. — Chart  showing  the  motor  points  for  stimulating  the  muscles  by  the 
galvanic  current:  1,  contraction  of  the  muscles  of  the  forehead  and  the  eyelids; 
2,  contraction  of  the  muscles  of  the  nose  and  upper  lip;  3,  contraction  of  the  muscles 
of  the  whole  half  of  the  face;  ^,  closure  of  the  jaws;  5,  turning  of  the  head  to  the 
opposite  side;  6,  turns  face  to  the  opposite  side,  the  ear  approaches  the  shoulder  of 
the  same  side;  7,  flexes  head  to  the  side,  raises  the  shoulder,  protrudes  the  lower 
jaw;  8,  raises  the  shoulder  and  draws  the  scapula  toward  the  spine;  9,  contraction 
of  the  deltoid;  10,  serratus  action,  scapula  pushed  forward  and  out;  11,  contraction 
of  almost  all  of  the  arm  muscles.  Erb's  point:  Get  action  on  the  biceps,  deltoid, 
brachialis  ant.,  and  supinator  long.     (White  and  JelUffe.) 


is  usually  a  history  of  throat  involvement.  The  most  common  forms 
of  paralysis  are  those  of  the  soft  palate  and  of  the  eye  muscles,  par- 
ticularly of  the  accommodation.  The  patient  often  shows  irregular 
heart  action,  with  dilatation  of  the  heart.  In  poliomyelitis  the 
paralysis  comes  on  within  a  few  days,  usually  within  the  first  eight 
days.  In  diphtheritic  paralysis  the  onset  is  later.  In  Rolleston's 
series,  on  which  I  commented  in  Progressive  Medicine  for  March, 


152 


DIAGNOSIS 


1914,  the  only  forms  of  paralysis  which  occurred  during  the  first 
two  weeks  were  those  involving  the  palate  and  the  so-called  cardiac 
paralysis.  The  ocular  paralyses  are  more  apt  to  occur  during  the 
fourth  and  fifth  weeks,  although  some  occur  in  the  third  week,  and 
paralysis  involving  the  lips,  pharynx,  or  diaphragm  almost  always 
occur  later  than  this,  that  is,  during  the  sixth,  seventh,  and  eighth 
weeks.  In  cases  seen  early  a  lumbar  puncture  will  settle  the  ques- 
tion, but  in  cases  occurring  late  in  which  no  history  can  be  obtained 
the  difficulties  of  diagnosis  may-  be  almost  insurmountable. 


JExtetisian  of  the  hand 


Supinator  long. 
ExtenSi.  carpi radihl* 


Extens.  Ind 
Abduct,  poll.  Ion 
Extens.  poll,  brev, 
( Ist.phalanx) 


Extension  of  hand  and 
fingers  ivith  separation  of 
:ihe  latter  and  slight 
1      flexion  of  two  distal 
phalanges. 


•  Emens.  carp,  ulnaris 


Extms.  jpoT,l.  long.  (^  la^t  phalanges) 


pduct.  min.  dig. 

Separation  of  the  fingers  and  loith  strong 
current  fie.cion  of  the  1st.  phalanges. 


Fig.  52. — Motor  points  for  the  muscles  of  the  dorsal  surface  of  the  arm  and  hand. 

(White  and  Jelliffe.) 


Electricity  in  Diagnosis. — The  electrical  examination  of  nerves 
and  muscles  is  one  which  requires  a  great  deal  of  practice  before 
satisfactory  results  can  be  obtained,  and  it  is  also  necessary  that 
the  patient  remain  in  a  perfectly  quiet  state.  With  children  this 
latter  condition  is  difficult  or  impossible  to  obtain  without  an  anes- 


ELECT RICirY  IN  DIAGNOSIS 


153 


thetic,  and  there  are,  perhaps,  but  few  cases  in  which  information 
of  sufficient  vahie  could  be  obtained  to  warrant  its  use.  No  one 
who  has  not  attempted  to  obtain  electrical  reactions  in  a  child 
can  realize  the  difficulty  of  the  task.  The  two  currents  which  are 
most  extensively  used  are  the  interrupted  or  faradic  and  the  con- 
tinuous or  galvanic  current.  In  order  to  test  the  reaction  of  the 
muscles  it  is  important  that  both  electrodes  be  in  close  contact 


Contraction  of  the  flex.  cavp.  ulnar., 
flex  dig.  coinmun.  prof.,  adduct.  xjoll 
all  muscles  of  hypotIi.enar  eminence 
interossei  and  ord.  and  Uth.  lumbrica 


Elex.  carp,  idnar  • 
Flex.profund,  ct^n^* 


Flex,  dig,  siibliiii.^p 
ii  d'  Hi 
Flexion  of '{lie  little  finger 
contraction  of  interossei,  ivth.  lunib.^  \         x 
adduct.  poll.,  and  deep  head  of  flex. 

poll,  brev  , 

Abduct.  mfn.»dig.  • 

flex. 
Opponensr} 


Flexion  of  1st.  phalanx  and  extens.  of 
2nd.  and  3rd. 


•Del'tc 


Biceps' 

Contraction  of  flexors  except 
flex,  carpi  ulnar,  and  flex.  dig. 
achia^is  int.. prof--  Contraction  of  thumb- 
muscles  except  adduct.  poll, 
and  id:  ii  lumtn-icales 
teres 
Supin.  long 

carp.-rad.  (flex,  of  the  hand  tcith 
ulnar  rotat.) 


Flex  dig.  siiblim. 


Abduct,  poll, 
ppponenspoll. 
^Flex.  brev.  poll, 
uct.  poll. 


Fig.  53. — Motor  points  for  the  muscles  of  the  palmar  surface  of  the  arm  and  hand 

(White  and  JelHffe.) 


with  the  body,  and  if  those  tipped  with  sponge  or  leather  are  used 
they  should  be  wet  in  salt  solution  first.  It  is  best  to  place  one 
electrode  over  the  motor  point  of  the  muscle  as  described  by  Erb, 
and  which  are  shown  in  the  plates.  The  other  electrode  may  be 
placed  at  some  distance,  so  that  the  contraction  of  the  one  which 
is  unimportant  does  not  interfere  with  the  reaction  of  the  muscle 
which  is  being  tested.    The  current  should  alwavs  be  tried  on  the 


154 


DIAGNOSIS 


operator  before  it  is  used  on  the  patient,  to  be  sure  it  is  not  too 
strong.  The  reaction  of  the  muscles  on  the  two  sides — that  is,  of 
the  sound  side  and  the  affected  side — should  be  compared.  The 
faradic  current  stimulates  the  muscle  through  the  motor  nerve,  and 
it  is  important  to  have  the  electrode  on  the  motor  point.  Reac- 
tions can  be  obtained  at  other  places,  but  not  so  satisfactorily.  In 
the  reaction  of  degeneration,  often  referred  to  as  R.  D.,  the  nerve 


Gluteus  max. 

iatid  nerve Flexion  of  the  lower  leg. 

BiscepsVf'mnrix  •    •  Seniitendinosis 
(long  head)  \^  •   jSemimeinbranosis 

(short  he 


N.  Peroneus 


Gastrocnemius 
(Ext.  head) 


Soleus'-'i 


Flex,  halluc.long. 


ITihiaTis;- flexion  of  the  foot  and  toes 

astrocnemiiLS 
(Int.  head) 

Salens 
Flex,  commun.  dig.  long. 

N.  Tibialis;- flexion  of  the  toes. 


Fig.  54. — Motor  points  for  the  muscles  of  the  posterior  surface  of  the  leg. 
(White  and  Jelliffe.) 


and  muscle  have  undergone  degeneration  and  the  motor  nerve  has 
lost  its  power  to  conduct  impulses  from  the  cord  to  the  muscles. 
In  this  case  there  is  no  response  to  the  faradic  current.  In  cases 
in  which  there  is  only  partial  degeneration  the  faradic  current 
reaction  will  be  found  to  be  decreased,  but  not  entirely  absent. 
The  galvanic  current  differs  from  the  faradic  in  that  it  stimulates 
the  motor-nerve  fiber  the  moment  of  closing  and  opening  the 
current.    The  nerve  fiber  is  not  stimulated  during  the  time  of  flow. 


ELECTRICITY  IN  DIAGNOSIS 


00 


The  muscle  fibers  are  stimulated  at  the  closing  and  opening  of  cur- 
rent, and  also  during  the  flow.  If  the  nerve  fiber  is  degenerated 
there  will  still  be  found  a  contraction  of  the  muscle  fiber  if  the 
galvanic  current  is  applied.  With  this  current  the  so-called  polar 
reactions  are  made.  The  reactions  at  the  time  of  closure  and  open- 
ing are  a  sharp  contraction  of  the  muscle,  which  remains  in  a 
condition  of  relaxation  during  the  flow  of  the  current.    In  normal 


Extension  of  the 

loicer  leg.  jV.  Cruralis 
Contraction  of  the  adductors 
N.  Obturato) 


Adduct.  mag. 
Additct.  tonb. « 


Va;sius  intern  us  * 


'Tensor  fascia  laU 


iceps  femoris 


•  Rectuslfenioris 


•  Vastus  externus 


Fig.  55. — Motor  points  for  the  muscles  of  the  anterior  surface  of  the  thigh. 
(.White  and  Jelliffe.) 


muscles  the  negative  pole,  also  known  as  the  kathode,  gives  a  greater 
reaction  at  the  closure  of  the  current  than  the  positive  pole  or 
anode.  The  reaction  of  degeneration  shows  that  the  muscle  fibers 
will  still  respond,  and  even  to  a  weaker  current  than  they  would 
under  normal  conditions.  The  change  is  in  the  reaction  to  the 
poles.  The  contraction  to  the  anode  or  positive  pole  is  now  greater, 
or  at  least  equal,  to  that  of  the  kathode.    Instead  of  the  twitching 


156 


DIAGNOSIS 


motion  of  before,  we  have  now  a  much  more  sluggish  reaction.  In 
the  cases  of  degeneration  there  is  present  a  slow  reaction  to  the 
galvanic  current,  but  the  anode  reaction  is  still  greater  than  the 
kathode. 


Tibialis  anfr— 1-* 
extens.  commun.  dig.  long'. 


&\N.  Peroneus;-  extension  of  the  ivhole 
foot  tvith  abduction. 
oPeroheus  long. 


Salens 


Extens.  halluf.'long.  »  Flex,  hallucis  long. 
I 


Interossei  dorsalisi^'- 


tens.jcommim.  dig.brev. 


Fig.  56. — Motor  points  for  the  muscles  of  the  anterior  surface  of  the  leg. 
(White  and  Jelliffe.) 


The  reactions  are  often  expressed  by  letters,  as  kathodal  closing 
contraction,  K  C  C.  The  reactions  of  a  healthy  muscle  as  the  cur- 
rent increases  in  strength  isKCC  >ACC>AOC  >KOC,  or 
this  may  be  expressed : 

1.  Weak  current  K  C  C 

2.  Medium  current KCCACC 

3.  Moderately  strong  current     .      .      .  KCC     ACC     AOC 

4.  Strong  current KCCACCAOCKOC 


CHAPTER    XL 
PROGNOSIS. 

The  prognosis  in  poliomyelitis  has  to  be  considered  from  several 
standpoints:  (1)  during  the  acute  attack  there  is  the  problem  as  to 
life  itself;  (2)  as  to  the  immediate  paralysis  and  its  extent;  (3)  as 
to  the  amount  of  paralysis  that  will  be  left;  (4)  as  regards  the 
recovery  of  the  function  and  its  relation  to  the  earning  of  a  living. 

As  regards  life,  the  problem  is  somewhat  like  that  of  any  other 
acute  infectious  disease,  but  it  has  the  difference  that  most  of  the 
deaths  are  due  to  involvement  of  the  respiratory  centers,  a  simul- 
taneous paralysis  of  the  intercostals  and  the  diaphragm  being  the 
usual  cause  of  the  fatal  outcome,  although  some  die  from  secondary 
reasons,  such  as  the  development  of  a  pneumonia.  The  statistics 
available  are  based  on  the  older  conception  of  the  disease  and  relate 
chiefly  to  the  frankly  paralyzed  cases.  The  mortality  rate  varies 
in  different  epidemics  from  10  to  about  25  per  cent.  There  are 
instances  on  record,  however,  in  which  the  mortality  was  even  very 
much  higher  than  this.  Wickman,  for  example,  in  a  small  epidemic 
of  26  cases,  saw  a  mortality  of  42.3  per  cent.  In  868  cases  reported 
by  Wickman  the  mortality  was  16.7  per  cent.,  which  represents 
perhaps  a  good  average.  A  low  mortality  and  a  high  mortality 
may  occur  in  the  same  year  in  different  parts  of  the  same  country. 
For  example,  Zappert  reported,  in  1908,  an  epidemic  in  Northern 
Austria  in  which  the  mortality  was  10.8  per  cent.,  while  Lindner 
and  jNIally^  reported  an  epidemic  in  Eastern  Austria  occurring  in 
the  same  year  with  a  mortality  of  22.5  per  cent.  The  table  on 
page  158  shows  the  comparison  of  some  of  the  foreign  and  American 
death-rates,  and  is  taken  from  the  Massachusetts  report  of  1910: 

The  younger  children  ha^  e  a  better  chance  for  life  than  the  older 
ones  or  adults.  In  Wickman's  cases  the  mortality  was  11.9  under 
eleven  years  of  age  and  27.6  between  twelve  and  thirty-two  years 
of  age. 

^  Deutsch  Ztsclir.  f.  Nervenki-auk.,  xxxvi,  3-43. 


158 


PROGNOSIS 


Comparison  of  Foreign  and  American  Death-rates.     From 
THE  Report  of  the  Massachusetts  Epidemic  of  1910. 


Year. 

Cases. 

Deaths. 

Mortality 
per  cent. 

Caverly,  Vt 

1894 

•     132 

18 

14.5 

Wickman,  Sweden  . 

1905 

868 

145 

16.7 

Leegaard,  Norway  . 

1905 

577 

84 

14.5 

Zappert,  Austria 

1908 

266 

29 

10.8 

Linder  and  Mally,  Austria 

1908 

71 

16 

22.5 

Fiirntratt,  Steiermark  . 

1908 

433 

57 

13.1 

Krause,  Germany    . 

1909 

633 

78 

12.3 

Miiller,  Germany     . 

1909 

100 

16 

16.0 

Peiper,  Germany 

1909 

51 

6 

11.7 

Eichelberg,  Germany    . 

1909 

34 

7 

20.6 

Massachusetts,  U.  S.  A. 

1907-1910 

1599 

125 

7.9 

Showing  Higher  Mortality  in  the  More  Advanced  Ages. 
From  the  Report  of  the  Massachusetts  Epidemic  of  1910. 


Wickman,  Sweden  . 
Leefraard,  Norway  ... 
Fiirntratt,  Steiermark  . 
Linder  and  Mally,  Austria 
Massachusetts,  1910,  U.  S.  A. 


Age, 

years. 

12  to  32 

15  to  30 

Over  17 

"     11 

"     10 


Per  cent. 
27.6 
25.8 
25.5 
50.0 
20.0 


Mortality   by   Age    (1909-10).     From  the   Report   of   the 
Massachusetts  Epidemic  of  1910. 

Age,  years.                                                                       Cases.            Deaths.  Per  cent. 

Under  1 82                 10  12.19 

1  to  10 945                 59  6.24 

Over  10 189                 28  14.81 

Totals 1216  97 

Average  mortality . .  7 .  90 


Mortality  by  Age.    Massachusetts  Epidemic  of  1910. 


Age,  years.  Cases. 

Under  1 38 

1  to  10 451 

Over  10 112 

Total 601 

Average  mortality 


Deaths. 

Mortality 
per  cent. 

3 

7.89 

39 

8.64 

12 

10.71 

54 


8.98 


There  is  no  way  to  tell  which  will  be  the  fatal  cases  and 
which  will  recover,  although  with  a  certain  amount  of  experience 
one  can  guess  roughly  at  the  ones  that  will  probably  terminate 
fatally.    As  death  is  very  largely  due  to  respiratory  paralysis  the 


MORTALITY  BY  AGE  159 

involvement  of  the  phrenic  and  intercostal  centers  is  always  watched 
for,  but  there  is  no  way  to  tell  whether  a  paralysis  will  extend  or 
not.  In  the  great  majority  of  cases  the  lesions  very  rapidly  attain 
their  maximum  extent  and  rarely  advance  after  that.  The  involve- 
ment of  centers  near  the  vital  ones  does  not  necessarily  mean  that 
the  disease  will  spread  to  that  center,  nor  does  the  involvement  of 
either  the  phrenic  or  intercostal  centers  alone  mean  a  fatal  prog- 
nosis. One  occasionally  sees  cases  recover  in  which  there  is  paraly- 
sis of  either  the  diaphragm  or  intercostals.  The  cases  simulating 
Landry's  paralysis  of  the  ascending  type  are  more  apt  to  go  on  to 
the  involvement  of  the  respiratory  centers  than  those  which  are 
struck  suddenly  without  any  tendency  to  extend.  As  a  general 
thing  the  fatal  cases  are  extremely  ill  during  the  first  few  days  and 
cases  that  have  extreme  prostration  at  the  onset  are  apt  to  terminate 
unfavorably.  Cases  high  up  in  the  cord  are  more  apt  to  prove  fatal 
than  those  in  which  the  lesion  is  lower,  and  Peabody,  Draper  and 
Dochez  found  that  all  of  their  fatal  cases  had  either  paralysis  of 
one  or  both  deltoids,  that  is,  the  cervical  cord  was  involved.  Another 
point  which  they  mention  which  we  have  been  able  to  verify  in  a 
number  of  instances  is  that  the  patients  who  are  profoundly  ill  and 
who  have  a  very  alert  cerebration  practically  all  die,  whereas  the 
cases  which  are  in  a  stuporous  condition  are  rarely  fatal.  One 
should  not  confuse  the  very  irritable  cases  with  alert  cerebration, 
because  the  marked  irritability  is  rather  a  favorable  sign,  if  anything. 

Wickman  found  that  death  most  often  occurred  on  the  fourth 
day  of  the  paralysis,  usually  between  the  limits  of  from  the  third 
to  the  seventh  day  after  the  loss  of  power  was  noticed.  If  one 
counts  from  the  beginning  of  the  disease  the  deaths  will  usually 
come  from  between  the  fourth  and  the  eighth  day.  After  eight 
have  elapsed  the  danger  of  death  from  the  poliomyelitis  itself  is 
certainly  very  slight  but  not  in  all  epidemics.  The  deaths  which 
take  place  after  this  are  apt  to  be  from  complications,  particularly 
pneumonia.  A  pneumonia  in  connection  with  a  respiratory  paraly- 
sis is  nearly  always  fatal,  although  not  necessarily  so.  The  treat- 
ment during  the  acute  stage  apparently  has  very  little  effect  on  the 
mortality.  Whether  the  serum  treatment  in  the  future  will  affect 
this  or  not  remains  to  be  seen. 

The  question  as  to  whether  paralysis  will  occur  or  not  in  a  given 
case,  and  what  its  extent  will  be,  is  a  very  difficult  one,  and  at  the 
present  time  we  do  not  believe  there  is  any  method  by  which  this 
can  be  determined.     The  severity  of  the  general  symptoms  bear 


160 


PROGNOSIS 


no  relation  to  the  occurrence  of  paralysis  or  to  its  extent.  One  may 
see  cases  with  extremely  severe  general  symptoms  at  the  onset 
who  recover  promptly  with  little  or  no  subsequent  paralysis,  and, 
on  the  other  hand,  one  sees  cases  beginning  mildly  with  a  most 
widespread  persistent  loss  of  power.  The  extent  of  the  paralysis  or 
its  occurrence  bears  no  definite  relation  either  to  pain  or  to  the 
reflexes.  The  reflexes  may  be  lost  and  recur  or  be  exaggerated  and 
still  there  may  be  no  definite  paralysis.  Draper  suggests  that  the 
cases  with  a  low  cell  count  do  not  develop  paralysis  and  those 
with  high  cell  count  usually  do,  although  there  are  many  excep- 
tions to  both  of  these.  After  thirty-six  hours  from  the  onset  the 
cell  count  and  spinal  fluid  have  little  prognostic  value.  In  fatal 
cases  very  high  cell  counts  were  seen  within  twelve  to  twenty-four 
hours  of  the  onset. 


Deaths  from  Poliomyelitis  by  Day  of  Disease. 
Epidemic  of  1916. 


New  York 


Total  deaths  to  August  31 
Under  investigation 


Total  included  in  this  study 


1962 
114 


1848 


Deaths  on  first  day 55 

"          second  day 179 

"          third  day 315 

"          fourth  day 369 

fifth  day 300 

"          sixth  day      . 182 

"          seventh  day 110 


Total  for  first  week 


1510 


Deaths  on  eighth  day  .      .            67 

"  ninth  day 41 

"  tenth  day 36 

"  eleventh  day 28 

"  twefth  day         16 

"  thirteenth  day 15 

"  fourteenth  day 8 


Total  in  second  week 


}11 


Deaths  on  fifteenth  day 11 

"  sixteenth  day 15 

"  seventeenth  day 8 


eighteenth  day 
nineteenth  day 


81  +  per  cent. 


11+  per  cent. 


6  y  3  +  per  cent. 
5  I 


"  twentieth  day 10 

"  twenty-first  day 5  J 

Total  in  third  week 60 

After  twenty-first  day 67  3  +  per  cent. 


CONDITION  OF  PATIENTS  AFTER  RECOVERY  161 

As  to  the  question  of  whether  a  paralyzed  muscle  will  regain  its 
function  or  not — in  a  general  way,  the  age  of  the  child  is  very  impor- 
tant and  \ery  young  children  are  more  apt  to  have  a  restoration  of 
function  than  older  children  or  adults.  One  natiu-ally  wonders  if 
this  is  due  to  it  being  easier  to  have  nervous  impulses  sent  along 
new  routes  in  the  young  than  it  is  after  the  child's  nervous  system 
has  become  more  or  less  fixed.  In  a  general  way  the  severer  the 
paralysis  at  the  onset  the  more  apt  there  is  to  be  permanency  of 
the  loss  of  power,  but  there  are  many  exceptions  to  this.  The 
paralysis  may  occm*  on  any  day  of  the  disease,  but  after  seven  or 
eight  days  there  is  little  or  no  danger  of  paralysis.  In  the  great 
majority  of  cases  the  paralysis  occiu-s  on  the  first,  second,  thhd,  or 
fourth  day.  There  are  some  instances  on  record  in  which  the  paraly- 
sis has  come  on  after  eight  days,  even  as  long  as  eight  weeks  being 
recorded,  but  one  rather  doubts  the  real  day  of  onset  in  these  late 
paralytic  cases. 

The  prognosis  as  regards  complete  recovery  and  recovery  of 
function  seems  to  have  varied  greatly  in  different  epidemics  and 
in  the  experience  of  different  observers.  Perhaps  the  variations 
are  due  to  the  amount  of  care  taken  in  making  the  after-studies. 
Wickman,  in  530  cases,  reports  56  per  cent,  as  paralyzed  and  4ri 
per  cent,  as  cured.  In  the  IMassachusetts  report  of  1910  there  were 
16.7  per  cent,  of  complete  recoveries.  In  the  New  York  epidemic 
of  1916,  2715  cases  discharged  with  paralysis  were  followed  up,  and 
of  these,  1SS5  had  a  serious  paralysis  of  one  or  both  legs  and  were 
unable  to  work  at  the  time  of  the  report.  There  were  530  partly 
paralyzed  in  the  legs,  but  able  to  walk,  and  273  had  one  or  both 
arms  totally  paralyzed.  In  foiu-  hospitals  under  the  New  York 
Health  Department,  in  which  3441  were  treated,  716  died,  or  16 
per  cent.  In  1223  cases  there  was  no  visible  paralysis  on  discharge, 
or  32.6  per  cent,  of  total  recoveries,  and  there  were  2256  cases  with 
visible  paralysis,  or  67.4  per  cent.  The  average  stay  in  the  hospital 
per  patient  was  32.4  days. 

Condition  of  Patients  after  Recovery.     ]\L^sachusetts 
Epidemic  of  1910. 

Cases.  Per  cent. 

Complete  recovery  without  atrophy 16  28.1 

Functional  recovery  with  atrophy 21  36.8 

Recovery  with  some  hypertrophy 3  5.3 

Recovery,  presence  or  absence  of  atrophy  imknown     .17  29.8 

As  regards  the  restoration  of  function,  the  problem  is  exceedingly 
difficult.     In  former  days  great  stress  was  laid  upon  the  value  of 
11 


162  PROGNOSIS 

electric  reactions,  and  the  studies  of  Duchenne,  of  Boulogne,  made 
many  years  ago,  covers  the  ground  satisfactorily  as  far  as  the  gen- 
eral practitioner  is  concerned.  He  summarized  the  question  as 
below:  "Diminution  of  electric  contractility  from  the  first  in  direct 
proportion  to  the  amount  of  damage  done  to  the  innervation  of  the 
paralyzed  muscles,  after  a  time  return  of  electric  contractility 
in  these  muscles  or  parts  of  muscles,  the  tissue  of  which  is  not 
changed."  The  whole  question  of  electric  reactions  in  poliomye- 
litis needs  to  be  restudied  by  specialists.  Very  rapid  and  complete 
atrophy  of  a  muscle  or  muscle  group  usually  means  the  destruction 
of  the  corresponding  nerve  cells  and  the  outlook  for  recovery  of  power 
is  poor,  but  not  hopeless,  but  there  are  some  exceptions  to  this. 
The  deltoid  usually  atrophies  very  quickly  and  completely.  Lovett 
has  suggested  that  in  muscles  which  remain  totally  paralyzed  to 
attempts  at  voluntary  contraction  at  the  end  of  three  months,  the 
outlook  for  any  degree  of  recovery  for  marked  function  is  not  good, 
but  he  also  added  that  the  situation  is  not  hopeless  in  these  cases. 
In  the  very  mild  cases  the  paralysis  may  last  but  a  short  time,  per- 
haps only  a  few  days,  although  it  seems  that  it  usually  remains  at 
least  seven  to  ten  days.  Ordinarily,  if  complete  recovery  is  going 
to  take  place  it  does  so  within  six  weeks,  although  it  may  be  delayed 
as  much  as  six  months.  After  this  time  complete  restoration  of 
function  is  very  rare,  although  it  may  occur  in  the  second  half 
of  the  first  year  and  in  a  very  few  cases  even  later  than  this.  What 
generally  happens  is  a  partial  recovery  of  the  muscle  power  with 
a  more  or  less  complete  restoration  of  function  which  may,  on 
superficial  observation,  look  like  complete  restoration. 

The  prognosis  as  regards  the  restoration  of  function  is  very  inti- 
mately connected  with  the  proper  treatment,  and  upon  this  too 
much  stress  cannot  be  laid.  It  means  at  the  onset  no  meddling 
therapeutics;  it  means  proper  rest  during  the  acute  stage,  with  the 
use  of  whatever  may  be  needed  to  prevent  deformity.  After  the 
acute  stage  it  means  careful  supervision  until  function  is  restored 
satisfactorily  or  for  a  period  of  at  least  two  years  or  longer,  during 
which  time  fatigue  must  be  carefully  guarded  against.  A  great 
deal  can  be  accomplished  by  means  of  massage  and  exercises,  par- 
ticularly under  trained  supervision.  The  best  results  have  been 
obtained  where  a  nurse,  expert  in  muscle  training,  has  been 
employed.    Lovett  and  Martin^  studied  a  certain  number  of  cases 

1  Am.  Jour.  Orthop.  Surg.,  July,  1916. 


CONDITION  OF  PATIENTS  AFTER  RECOVERY  103 

with  reference  to  the  effect  of  different  forms  of  treatment,  and  they 
found  that  the  chances  for  improvement  with  expert  daily  treat- 
ment were  6  to  1;  with  supervised  home  exercises,  3.5  to  1 ;  whereas 
without  supervision  it  was  2.8  to  1.  They  also  studied  44  totally 
paralyzed  muscle  groups  after  the  lapse  of  one  year.  In  48  per 
cent,  of  these  after  two  months'  training  there  was  a  certain  amount 
of  demonstrable  power  developed,  whereas  in  a  like  number  of 
cases  of  the  same  kind  in  which  there  was  no  treatment  a  return  of 
power  was  noted  in  but  27  per  cent. 

Another  point  in  prognosis  consists  of  the  question  of  the  danger 
of  subsequent  cord  affections.  The  statement  is  often  made  that 
individuals  who  have  suffered  with  poliomyelitis  are  more  liable 
to  organic  nerve  lesions  later  on.  As  to  this  there  seems  to  be  some 
question,  inasmuch  as  comparatively  few  cases  have  been  actually 
reported,  and  one  must  always  allow  for  the  possibility  of  coinci- 
dence. These  individuals  are  probably  more  subject  to  functional 
nerve  disturbances,  particularly  those  who  have  extensive  loss  of 
power.  Of  the  effects  that  have  been  described  in  association  with 
old  lesions  are  chronic  muscular  atrophy,  progressive  myopathy, 
and  multiple  sclerosis.  Crouzon  has  described  a  man  who  had 
poliomyelitis  in  childhood,  and  between  eighteen  and  forty  years 
of  age  had  nine  different  attacks  of  temporary  hemiplegia.  Pierre 
Marie  has  called  attention  to  a  form  of  sclerosis  coming  on  about  a 
decade  after  the  acute  attacks,  which  he  called  "scoliose  tardive." 

Progressive  muscular  atrophy  is  another  complication  that  has 
been  reported  a  number  of  times.  It  was  first  noted  by  Raymond.^ 
Similar  cases  have  also  been  described  by  Seeligmiiller  and  others. 

1  Gaz.  mcd.,  1875,  No.  17. 


CHAPTER    XII. 

TREATMENT. 

For  purposes  of  description  we  shall  use  the  suggestion  of  Lovett 
and  divide  the  disease  into  three  stages:  (1)  the  acute  stage,  from 
the  onset  to  the  diappearance  of  the  tenderness;  (2)  the  convales- 
cent stage,  beginning  with  the  disappearance  of  the  tenderness 
through  the  period  in  which  spontaneous  improvement  is  marked, 
a  period  roughly  estimated  at  about  two  years;  (3)  the  chronic 
stage,  when  the  condition  has  become  more  or  less  fixed,  the 
extent  of  the  paralysis  more  or  less  definitely  determined,  and 
any  deformities  definitely  established. 

THE    ACUTE    STAGE. 

As  soon  as  diagnosis  is  made,  or  even  before  if  the  child  has 
fever,  the  child  should  be  put  to  bed  and  kept  there.  In  the  more 
severe  cases  this  is,  of  course,  imperative,  but  in  the  very  mild 
cases  there  may  be  a  little  difficulty  experienced  in  getting  the  parents 
to  understand  the  necessity  of  as  near  absolute  rest  as  possible,  and 
it  may  be  hard  to  control  the  child.  Efforts  should,  however,  be 
made  in  this  direction,  as  during  the  inflammatory  stage  any  exer- 
cise and  moving  about  must  necessarily  increase  the  amount  of 
blood  in  the  spinal  cord  and  also  causes  action  on  the  part  of  the 
motor  cells  which,  from  both  theoretic  and  practical  consider- 
tions,  should  be  kept  as  much  at  rest  as  possible,  so  as  to  allow  of 
the  greatest  amount  of  repair.  In  cases  that  are  extensively  par- 
alyzed it  will  be  found  a  great  advantage  in  the  early  stages  to  apply 
a  plaster  jacket  and  cast  to  the  legs,  a  procedure  which  greatly 
facilitates  the  care  of  these  patients,  and  if  tenderness  is  present, 
certainly  does  much  to  lessen  the  suffering.  The  casts  should  be 
cut  at  the  end  of  ten  days  to  three  weeks,  and  in  such  a  manner  as  to 
allow  the  patient  to  be  lifted  out  for  purposes  of  bathing  and  also 
to  allow  a  better  circulation,  and  the  patient  may  spend  part  of 
the  time  in  the  cast  and  part  of  it  out,  depending  upon  the  condi- 
tion.    During  this  acute  stage,  as  long  as  tenderness  is  present, 


ACUTE  STAGE  165 

unless  it  lasts  an  undue  length  of  time,  it  is  best  to  omit  any 
manipulation  and  also  the  use  of  massage  or  electricity. 

Pain  and  Tenderness. — These  are  best  combated  by  absolute 
rest,  by  casts,  by  protecting  the  patient  from  the  bedclothes  with 
suitable  frames,  and  by  the  application  of  heat.  The  affected  part 
may  be  wrapped  in  flannel  and  heat  supplied  under  the  bedding 
frame  by  use  of  some  of  the  electric  devices  or  by  hot- water  bottles 
or  the  like,  or  by  hot  sand-  or  salt  bags.  Another  thing  which  often 
gives  great  relief  is  to  have  the  patient  placed  in  a  very  warm 
bath,  but  this  is,  perhaps,  as  well  not  used  during  the  first  two 
weeks  except  in  carefully  selected  cases.  This  is  a  very  old  form  of 
treatment,  and  is  mentioned  by  Badham.  In  some  cases  the  pain 
may  be  so  severe  as  to  necessitate  the  use  of  anodynes.  For  this 
purpose,  e^•e^ything  else  being  equal,  we  have  found  a  combination 
of  codein  sulphate  and  antipjTin  to  be  of  greatest  service.  It  gives 
greater  relief  from  pain  than  almost  any  combination  of  drugs  that 
we  have  used,  and  is  followed  by  less  after-effects.  The  antipyrin 
may  be  omitted  in  case  the  general  circulation  is  weak,  or  it  may 
be  replaced  by  an  equal  amount  of  sodium  bromide.  We  generally 
prescribe  ^  grain  of  codein  with  1  grain  of  antipjTin  for  a  child  a 
year  old,  and  this  amount  may  be  repeated  at  intervals  of  two 
hours,  or  in  severe  cases  at  intervals  of  an  hoiu-  until  relief  is 
obtained,  or  somewhat  larger  doses  may  be  used  if  the  smaller  ones 
do  not  take  effect.  In  older  children  a  Ye,  tV.  h  or  I  grain  may  be 
used  in  combination  with  from  2  to  4  grains  of  antipjTin.  Syrup 
of  orange  makes  a  very  excellent  vehicle  and  is  rarely  objected  to. 
Great  care  should  be  taken  in  very  ill  patients  to  prevent  bed-sores ; 
the  skin  over  the  points  of  pressure  should  be  bathed  with  alcohol 
two  or  three  times  a  day  and  carefully  powdered  with  talcum.  In 
patients  who  have  lost  control  of  the  sphincter  there  is  usually  also 
an  extensive  paralysis,  and  these  cases  are  most  easily  handled  by 
putting  them  up  in  casts  and  placing  them  in  a  frame  over  a 
bed-pan. 

Dyspnea  and  Respiratory  Failure.— These  may  be  treated  by  rais- 
ing the  foot  of  the  bed,  if  the  patient's  lungs  are  perfectly  clear,  by 
the  administration  of  oxygen  with  an  ordinary  cone  inhaler,  or  by 
the  use  of  some  form  of  pulmotor  or  lungmotor,  either  with  or 
without  the  use  of  oxygen.  In  cases  in  which  there  has  been  a 
paralysis  of  the  respiratory  centers,  when  the  heart  is  not  involved, 
have  been  kept  alive  for  mam'  hom-s  by  use  of  artificial  respiration 
and  oxygen.    In  one  instance  Landolt  kept  a  child  alive  for  seventy- 


166  TREATMENT 

two  hours  by  this  means,  but  the  patient  eventually  died.  In  cases 
in  which  the  lesion  appears  from  above  and  spreads  downward, 
Meltzer  believes  that  the  vasomotor  center  may  be  first  involved 
and  that  death  may  be  due  to  the  rapid  fall  of  blood-pressure.  All 
of  the  cases  with  which  we  are  familiar,  and  in  which  artificial  respi- 
ration has  been  done,  have  died;  but  it  seems  perfectly  possible 
that  there  may  be  cases  in  which,  during  the  period  of  artificial 
respiration,  the  disease  may  cease  to  extend  and  recovery  may 
take  place.  Cases  with  threatened  respiratory  involvement  might 
be  particularly  suitable  for  the  use  of  immune  serum,  or  one  might 
try  the  use  of  epinephrin,  according  to  Meltzer's  idea,  which  is 
given  more  fully  elsewhere. 

Lumbar  Puncture. — Great  relief  is  afforded  in  many  instances, 
particularly  in  the  meningitic  type,  by  relieving  the  intracranial 
pressure  by  lumbar  puncture.  When  withdrawing  the  fluid  is 
beneficial  a  lumbar  puncture  may  be  repeated  at  intervals,  to  be 
decided  upon  by  the  condition  of  the  patient.  The  patient  should 
be  carefully  watched  while  the  fluid  is  being  withdrawn  and  the 
procedure  stopped  at  once  in  case  of  any  untoward  symptoms. 
(See  section  on  Lumbar  Puncture.) 

Use  of  Drugs. — As  far  as  we  know  there  are  no  drugs  of  any  value 
in  the  treatment  of  the  disease  except  the  well-known  remedies 
that  are  used  for  the  relief  of  pain  or  to  produce  sleep,  or  as  tonics, 
or  for  their  special  influence  upon  respiration,  circulation,  and  the 
like.  Codein  and  antipyrin  are  most  suited  for  the  relief  of  pain, 
iron  and  arsenic  as  tonics,  and  some  of  the  bitter  drugs,  with  small 
amounts  of  alcohol,  for  the  loss  of  appetite,  such  as  elixir  of  cinchona 
and  elixir  of  calisaya.  To  stimulate  respiration  and  circulation  very 
quickly  one  may  give  aromatic  spirits  of  ammonia  by  mouth  or  epi- 
nephrin hypodermically.  When  time  is  not  such  a  big  factor,  but 
when  prompt  results  are  desired,  10  per  cent,  camphorated  oil 
may  be  given.  It  should  be  injected  directly  into  the  muscles, 
either  in  the  gluteal  region  or  the  outer  side  of  the  thigh.  Less 
quick  action  may  be  obtained  by  using  atropin.  Digitalis  is  the 
best  heart  stimulant,  either  the  fluidextract  or  tincture,  by  mouth, 
or  what  is  known  as  Merck's  digitalin,  hypodermically.  We  are 
distinctly  against  indiscriminate  drugging  and  do  not  believe  that 
very  much  can  be  accomplished  by  the  use  of  medicine  except 
when  given  with  the  greatest  amount  of  skill  and  judgment.  Hexa- 
methylenamin  has  been  suggested,  but  certainly  has  no  value  in 
the  cure  of  the  disease,  although  it  may  have  some  in  its  preven- 


ACUTE  STAGE  167 

tion.  (See  same.)  Many  drugs  have  been  suggested,  among  others, 
quinine  and  urea  hydrochloride.  In  the  New  York  epidemic  of 
1916  the  report  of  the  Board  of  Health  contains  the  records  of  6 
cases.  Those  under  five  years  of  age  were  given  5  grains  intra- 
muscularly and  then  3  grains  by  mouth  every  three  hoiu-s.  Children 
over  five  years  of  age  were  given  10  grains  intramuscularly  and  5 
grains  ever}'  tlu-ee  hours  for  twenty-four  hours.  They  assume  that 
the  drug  does  not  arrest  severe  cases,  does  not  hasten  recovery 
from  paralysis,  and  does  not  absolutely  prevent  paralysis  when 
given  in  the  early  stage,  but  it  was  thought  that  it  might  be  of  some 
benefit  in  the  preparalytic  stage.  In  this  connection  one  should 
call  attention  to  the  fact  that  quinine  has  been  recommended  in 
rabies,  which  also  affects  the  central  nervous  system,  but  it  has 
been  definitely  proved  to  be  of  no  value. 

Serum  Therapy. — The  basis  for  using  a  serum  in  this  disease 
rests  primarily  on  the  fact  that  Flexner  and  Lewis,  in  1910,  demon- 
strated that  monkeys  that  had  had  the  disease  and  recovered  could 
not  be  reinoculated.  This  was  confirmed  by  other  investigators. 
Subsequently,  Romer  and  Joseph  demonstrated  that  there  are 
immune  bodies  in  the  blood  of  such  monkeys  which  would  neutralize 
the  virus  when  mixed  with  it  in  a  test-tube,  and  Levaditi  and  Xetter, 
and  also  Flexner  and  Lewis,  showed  that  the  same  was  true  with 
the  blood  from  human  beings  who  had  recovered  from  an  attack. 
Flexner  and  Lewis  after  this  demonstrated  that  monkeys  which 
were  actively  immunized  showed  the  presence  of  the  same  immune 
bodies.  Flexner  and  Lewis  then  demonstrated  that  the  serum  from 
monkej^s  or  from  individuals  who  had  had  the  disease,  injected 
into  animals  with  the  virus,  even  from  eighteen  to  twenty-four 
hoiu-s  afterward,  and  repeated  during  several  days,  would  either 
inhibit  development  of  the  disease  or  limit  its  ravages  if  it  devel- 
oped at  all.  The  disease  could  be  prevented  by  the  subdural  injec- 
tion of  the  serum,  either  after  the  injection  of  the  virus  into  the 
blood  or  directly  into  the  meninges.  In  the  monkey  the  first 
symptoms  of  the  disease  are  only  from  ten  to  twenty-four  hours 
before  the  beginning  of  the  paralysis,  and  this  usually  occurs  from 
six  to  seven  days  after  the  inoculation.  Fortunately,  in  man  the 
disease  does  not  develop  quite  as  promptly,  and  the  preparal^iiic 
stage  is  ordinarily  from  two  to  four  days.  The  first  observations 
on  using  this  serum  in  man  were  made  b}'  Netter,^  Xetter  and 

1  Bull,  de  I'Acad.  lued..  October  12,  1915. 


168  TREATMENT 

Salanier/  and  Netter.^  The  serum  was  taken  from  individuals  who 
had  had  paralysis,  and  even  thirty  years  after  an  attack  the  immune 
bodies  may  still  be  demonstrated.  When  it  was  possible,  however, 
they  preferred  cases  in  which  the  paralysis  was  of  not  more  than 
five  years'  standing.  The  individuals  were  carefully  examined  and 
the  blood  controlled  by  a  Wassermann  reaction.  The  introduction 
of  human  serum  into  the  spinal  canal  was  generally  very  well  toler- 
ated, but  it  causes  an  inflammatory  reaction  of  the  meninges,  as  is 
shown  by  specimens  of  the  fluid  drawn  after  subsequent  puncture, 
the  fluid  at  this  time  being  cloudy  and  containing  fibrin.  The 
albuminuria  is  increased  and  the  number  of  cells  also  increases,  the 
polymorphonuclear  cells  predominating.  Sometimes  this  fluid  will 
produce  a  yellowish  clot,  and  many  times  there  are  no  symptoms 
of  any  change  going  on,  but  occasionafly  there  may  be  pain  along 
the  spine,  with  stiffness  of  the  neck  and  body  and  slight  elevation 
of  temperature.  Only  twice  in  32  cases  was  there  any  alarm  caused 
by  the  injection  of  the  serum.  ■  Netter  in  his  32  cases  had  6  rapid 
and  complete  cures,  3  cases  so  much  improved  as  to  approach  a 
perfect  cure,  7  were  markedly  benefited,  and  5  appreciably  so,  but 
in  these  the  influence  of  the  serum  was  doubtful.  In  3  cases  the 
course  of  the  disease  was  not  modified,  and  8  patients  died,  7  from 
bulbar  paralysis. 

Netter  believes  that  the  serum  is  capable  of  stopping  the  course* 
of  the  paralysis  or  even  causing  it  to  disappear  if  already  started. 
He  thinks  that  if  it  is  given  in  the  preparalytic  stage  it  may  prevent 
the  occurrence  of  paralysis.  The  serum  should  be  used  within  the 
first  four  days  to  be  efficacious,  as  after  that  he  does  not  expect 
any  real  benefit.  In  one  instance  they  did  inject  the  serum  in  the 
preparalytic  stage,  and  there  was  no  subsequent  paralysis. 

Schwartz^  reports  21  cases  in  which  he  used  a  human  convales- 
cent serum.  Of  these,  9  recovered  without  paralysis.  In  another 
series  of  21  cases  that  were  untreated,  17  recovered,  the  latter 
figures  are  the  better.  In  the  New  York  epidemic  of  1916  a 
number  of  observers  have  used  the  serum.  Amoss  and  Chesney^ 
studied  26  cases  treated  with  human  serum  from  recovered  and 
convalescent  cases.  Twelve  of  the  cases  showed  paralysis  at  the 
time  the  serum  was  first  given,  1  patient  died,  2  showed  some  exten- 

1  Bull,  et  Tiiem.  de  la  Soc.  rned.  deshop.  de  Paris,  March  23,  1916,  p.  299. 
^  Arch,  de  mod.  des  enfants,  January,  1916,  p.  1. 
*Arch.  Ped.,  November,  1916,  xxxiii,  859. 
4  Jour.  Exper.  AJed.,  April  1,  1917,  xxv,  581. 


ACUTE  STAGE 


1G9 


slon  of  the  paralysis,  while  the  remaining  9  showed  no  increase  in 
the  amount  of  paralysis.     In  14  cases  in  which  no  paralysis  was 


TEfiP. 

104 
103 
102 
101 
100 
99 

3 

4 

5 

,6 

1 

6 

?l 

1 

1 

1 

\ 

r 

/ 

1 

/ 

\ 

/ 

c 

/ 

1 

^ 

B 

1 

- 

,/ 

V 

\/ 

^ 

\, 

^ 

V 

Fig.  57. — Temperature  curve  of  a  patient  with  poliomyelitis  who  developed  a  facial 
paralysis  eighteen  hours  after  the  first  dose  of  immune  serum.  This  patient  made  a 
complete  recovery.  C,  injection  of  20  c.c.  immune  serum  C;  B,  injection  of  15  c.c. 
immune  serum  B.  (Zingher,  Journal  of  the  American  Medical  Association,  March 
17,  1917,  p.  820.) 

detected  at  the  time  the  serum  was  administered,  2  died  from  respi- 
ratory failure,  2  others  developed  some  degree  of  weakness  or  par- 
tial paralysis,  and  the  remaining  10,  or  71  per  cent.,  did  not  show 


Fig.  58. — Typical  curve  in  preparalytic  case  of  poliomyelitis  in  which  immune 
serum  was  given  and  which  ended  in  complete  recovery.  B,  injection  of  15  c.c. 
immune  serum  B.  (Zingher,  Journal  of  the  American  Medical  Association,  March 
7,  1907,  p.  818.) 


any  paralysis.      They  believe  that  the   serum  should  be  injected 
both  intraspinally  and  into  the  general  circulation,  either  directly 


170  TREATMENT 

into  the  veins  or  into  the  subcutaneous  tissue.  In  the  hospitals 
under  the  New  York  Health  Department  a  number  of  cases  were 
treated,  and  they  found  that  with  a  few  cases  three  or  four  hours 
after  the  injection  of  the  serum  there  was  a  sharp  rise  in  the  tem- 
perature, while  in  the  other  cases  the  temperature  remained  rela- 
tively the  same  for  hours  and  then  began  to  fall.  In  the  progressive 
cases  which  resulted  fatally  the  temperature  continued  to  climb 
until  death  resulted.  As  a  rule,  after  the  injection  there  were  more 
or  less  signs  of  meningeal  irritation  marked  by  stiffness  of  the  head 
and  back,  general  hyperesthesia,  increased  irritability,  and,  in  the 
more  severe  cases,  by  stupor  or  delirium.  In  some  cases  the  second 
dose  was  given  twenty-four  hours  after  the  first,  and  in  two  cases 
the  third  dose  was  administered.  The  serum  was  used  in  15  c.c. 
amounts  and  injected  intraspinally.  The  condition  was  repeated 
when  the  general  condition  did  not  seem  better,  when  the  temper- 
ature remained  up  and  there  was  still  evidence  of  progressive 
involvement,  and  when  there  was  no  well-marked  sign  of  menin- 
geal irritation  after  the  first  dose.  The  New  York  report  goes  on  to 
state  that  the  serum  was  used  in  a  large  number  of  cases  with  some 
beneficial  result,  but  none  of  these  gave  sufficient  evidence  of  cura- 
tive effect  to  adopt  the  use  of  such  serum  for  the  specific  cure  of  the 
disease.  In  the  cases  that  are  paralyzed  at  the  time  the  serum  is 
given  the  results  do  not  seem  to  justify  its  use,  although  we  have, 
perhaps,  not  sufficient  evidence  at  hand  to  be  too  dogmatic  on  this 
point.  One  thing  is  clearly  brought  to  mind,  and  that  is  the  neces- 
sity for  very  early  diagnosis  and  the  very  early  administration  of 
the  serum  if  it  is  to  be  used  at  all.  There  is  at  present,  however, 
no  way  of  telling  how  many  cases  seen  in  the  preparalytic  stage  are 
going  to  be  paralyzed,  so  it  is  that  exceedingly  difficult  or  impos- 
sible to  estimate  the  favorable  results  obtained  by  using  the  serum. 
The  whole  subject  needs  much  further  study,  and  if  the  serum  is 
used  its  preparation  should  only  b«»  undertaken  by  one  skilled  in 
laboratory  technic  and  the  administration  by  one  thoroughly  famil- 
iar with  the  lumbar  puncture.  In  meningitis  the  lesion  is  more  on 
the  surface  and  the  use  of  the  serum  does  not  tend  to  set  up  any 
irritation,  but,  on  the  other  hand,  the  fluid  clears  on  its  use  and 
the  local  condition  is  improved.  In  poliomyelitis  there  is  usually 
an  active  increase  in  the  cells,  the  exudate  being  composed  of  about 
95  per  cent,  polynuclears  and  the  number  varying  from  50  to  1000 
per  millimeter.  The  fluid  at  times  is  exceedingly  turbid  and  seems 
almost  purulent,  but  is  sterile. 


ACUTE  STAGE  171 

Method  of  Preparing  Serum. — The  following  is  the  method  used 
by  the  workers  of  the  New  York  Health  Department  during  the 
epidemic  of  1910,  and  the  technic  is  taken  from  their  report: 

To  obtain  the  immune  serum  the  blood  is  drawn  from  suitable 
donors  in  quantities  varying  with  the  age  and  the  apparent  hemo- 
globin content  of  the  individual.  On  the  average  it  is  safe  to  with- 
draw 2  ounces  from  children  nine  to  ten  years  of  age,  3  or  4  ounces 
from  children  twelve  to  thirteen  years  of  age,  4  to  6  ounces  from 
individuals  eighteen  years  of  age  and  over.  Adults,  especially  the 
robust,  full-blooded  kind,  average  10  to  16  ounces  of  blood.  Similar 
amounts  can  be  withdrawn  again  after  an  interval  of  two  or  three 
weeks.  The  blood  is  best  withdrawn  by  using  a  15-gauge  platinum 
or  steel  needle.  In  children  and  stout  persons  with  small  or  indis- 
tinct veins  a  17-gauge  needle  attached  to  a  1-ounce  Record  sjTinge 
may  be  satisfactory-.  The  blood  is  collected  in  small  glass  bottles 
in  quantities  of  1  or  2  ounces  and  given  a  long  slant,  so  as  to  obtain 
as  long  a  surface  for  the  serum  as  possible.  The  blood  is  allowed 
to  cool  and  the  bottles  are  placed  in  the  ice-box  during  the  first 
twenty-four  hours  to  allow  the  separation  of  the  serum.  This  is 
decanted  the  following  day  and  centrifugalized  to  free  it  from 
pieces  of  blood  clot  and  red  blood  cells.  To  the  serum  is  added 
0.2  per  cent,  of  trikresol.  This  increases  the  local  irritant  action 
of  the  serum,  and  it  may  be  found  advisable  not  to  add  it.  The 
serum  is  then  allowed  to  stay  in  the  ice-box  forty-eight  hours, 
during  which  time  there  is  a  precipitation  of  a  fine  cloud  that 
appears  after  the  addition  of  the  trikresol.  After  this  is  separated 
the  serum  is  removed  from  it.  The  serum  is  then  passed  through 
a  Berkefeld  stone  filter,  bottled  in  quantities  of  15  c.c.  and  kept 
cold  in  dark  amber  or  blue  bottles  in  the  ice-box. 

Duration  and  Efficiency  of  the  Servm. — If  the  serum  has  been 
preserved  with  trikresol  or  handled  with  sterile  precautions  after 
it  has  been  passed  through  a  Berkefeld  filter  and  it  is  fterward 
kept  in  a  cold  place  it  will  probably  remain  efficient  in  its  specific 
content  for  several  weeks.  The  serum  obtained  during  the  New 
York  epidemic  of  1916  was  used  up  almost  as  fast  as  it  was  obtained. 
Some  kept  four  to  six  weeks,  however,  seemed  as  active,  therapeu- 
tically, as  the  more  recently  drawn.  In  an  emergency,  or  when 
the  facilities  for  treating  with  serum  are  not  obtainable,  blood  may 
be  simply  drawn  under  aseptic  conditions  in  a  vessel  with  glass 
beads,  shaken  up  and  centrifugalized,  or  the  serum  may  be  drawn 
in  the  usual  way  and  allowed  to  separate  for  a  few  hours  and 


172  TREATMENT 

promptly  used,  disregarding  the  presence  of  a  few  red  blood  cells. 
The  serum  probably  owes  its  action  (1)  to  the  presence  of  specific 
immune  bodies,  and  (2)  to  its  action  as  normal  human  serum  as 
such.  The  serum  should  not  be  heated.  The  donors  should  be  free 
from  syphilis,  as  demonstrated  by  a  negative  Wassermann  reaction, 
and  it  should  be  definitely  ascertained  that  the  person  has  actu- 
ally had  poliomyelitis  and  not  a  Bell's  palsy  or  syphilitic  paralysis, 
an  ordinary  hemiplegia,  or  tuberculosis  of  the  joints. 

The  length  of  time  the  immune  bodies  last  in  the  body  is  a  matter 
of  conjecture.  Flexner  and  Amoss^  report  an  instance  in  which 
they  found  the  immune  bodies  on  the  sixth  day  of  the  disease,  and 
they  have  been  found  years  afterward.  Netter  is  of  the  opinion 
that  the  most  potent  serum  is  found  between  three  months  and 
four  years  after  an  attack  of  the  disease. 

Flexner  and  Amoss^  have  shown  that  the  cerebrospinal  fluid 
taken  very  early  and  quite  late  exhibits  no  neutralizing  action  on 
poliomyelitic  virus,  and,  indeed,  the  neutralizing  principles  have 
only  been  found  very  exceptionally  in  the  cerebrospinal  fluid.  They 
have  also  shown  that  the  immune  bodies  may  be  present  in  the 
blood  as  early  as  the  sixth  day  of  the  disease  and  that  the  injec- 
tion of  sterile  horse  serum  into  the  meninges  in  monkeys  increases 
their  permeability,  and  this  permits  the  immunity  principles  injected 
into  the  blood  to  pass  into  the  cerebrospinal  fluid.  In  monkeys 
that  have  been  given  injections  of  immune  blood,  the  passage  into 
the  cerebrospinal  fluid  takes  place  during  a  rather  short  space  of 
time,  and  apparently  only  while  the  inflammatory  reaction  pro- 
duced by  the  horse  serum  is  at  its  height.  Normal  serum  injected 
intraspinally  into  monkeys  apparently  does  not  exert  any  curative 
action.  Inasmuch  as  the  immunity  principles  appear  in  the  blood 
only  after  several  days  the  employment  of  normal  horse  serum, 
which  seems,  if  it  has  any  action,  it  is  through  increasing  the  per- 
meability of  the  meninges,  permitting  the  escape  of  circulating 
immunity  principles  in  the  blood;  but  as  these  are  not  present 
during  the  first  few  days  of  the  illness  it  would  seem  decidedly 
preferable  to  use  an  immune  serum. 

Intravenous  and  Subcutaneous  Injection.^ — The  results  where  a 
combined  intraspinal  and  intravenous  injection  has  been  made  are 
somewhat  more  convincing  than  those  based  on  the  intraspinal 
injection  alone. 

1  Jour.  Exper.  Med.,  1917,  xxv,  499.  '  2  Ibid.,  April  1,  1917,  p.  499. 

'  Amoss  and  Chesney:  Jour.  Exper.  Med.,  1917,  xxv,  581. 


ACUTE  STAGE  173 

Draper  suggests  the  use  of  a  large  intravenous  or  subcutaneous 
dose  in  cases  before  there  are  signs  of  involvement  of  the  central 
nervous  system  and  in  which  there  is  a  negative  spinal  fluid  where 
the  child  has  been  associated  with  another  case.  After  ten  or 
twelve  hours  a  second  puncture  should  be  made  and  if  changes 
are  found  then  to  use  the  serum  intraspinally  and  another  dose 
intravenously  or  subcutaneously. 

A?i  Antiyoliomyelitis  Horse  Serum. — In  1910  Flexner^  attempted 
to  produce  an  antipoliomyelitis  horse  serum,  but  after  treating  a 
single  horse  for  many  months  did  not  find  any  immune  bodies  that 
had  any  restraining  effect  on  the  virus,  either  in  vitro  or  within 
the  body.  We  do  not  know  of  any  other  observations  of  this  kind 
until  Neustaedter  and  Banzhaf  ^  reported  the  results  of  some  obser- 
vations made  in  the  Research  Laboratory  of  the  Department  of 
Health  of  New  York  City.  Any  work  done  under  Dr.  William  H. 
Park,  director  of  the  laboratory,  is  worthy  of  most  careful  consid- 
eration. It  seems  that  the  destructive  action  of  the  virus  is  prob- 
ably not  due  to  an  exotoxin  but  to  the  ability  of  the  virus  to  multiply 
rapidly.  They  therefore  thought  it  advisable  to  see  if  the  horse 
would  react  to  an  endotoxin,  and  since  Flexner  obtained  no  results 
by  using  large  amounts  of  the  filtrates  of  the  active  virus,  and  exo- 
toxins and  endotoxins  cannot  be  produced  by  the  Flexner  and 
Noguchi  methods  of  culture,  the  authors  in  question  attempted  to 
obtain  an  endotoxin  by  digesting  the  germ  in  the  filtrate  of  a  brain 
and  cord  emulsion  of  trypsin  in  10  per  cent,  glycerin  solution.  The 
endotoxin  could  not  be  demonstrated,  but  at  the  end  of  August 
they  started  to  prepare  it,  and  early  in  September  started  to  inject 
it  into  a  horse.  Five  different  injections  were  made,  ending  in 
November,  and  two  weeks  later  the  horse  was  bled  and  the  serum 
prepared.  Five  neutralization  experiments  were  made  on  monkeys, 
all  of  which  were  positive.  On  account  of  the  scarcity  of  monkeys 
not  as  many  observations  were  made  as  would  otherwise  have  been 
done,  but  the  authors  feel  that  from  their  results  they  are  justified 
in  using  the  serum  in  human  cases,  especially  if  human  serum  is 
unobtainable. 

Following  is  the  protocol  of  their  first  observation : 

Observation  1. — December  6,  1916,  monkey  3  (mangabey)  was 
injected  intracerebrally  with  0.5  c.c.  of  a  5  per  cent,  suspension  of 
an  eighth  generation  monkey  virus,  and  at  the  same  time  20  c.c. 

1  Jour.  Am.  Med.  Assn.,  September  24,  1910,  p.  1112, 

2  Ibid.,  May  26,  1917,  p.  1531, 


174  TREATMENT 

of  the  serum  intramuscularly.  Twenty-four  hours  afterward  daily 
injections  were  begun  of  3  c.c.  of  the  serum  intraspinally  and  17 
c.c.  intramuscularly.  These  were  given  for  seven  days,  when  it 
was  considered  wise  to  cease  treatment.  The  animal  remained  well 
up  to  December  17,  four  days  after  the  last  treatment,  when  it 
seemed  ill  at  ease.  December  18  the  right  extensor  cruris  was  weak. 
On  this  day  he  received  3  c.c.  of  the  serum  intraspinally  and  17 
c.c.  intramuscularly.  December  19,  he  seemed  to  favor  the  left 
leg  also.  On  this  day  and  the  following  he  received  3  c.c.  of  the 
serum  intraspinally  and  17  c.c.  subcutaneously.  The  animal  began 
to  improve  in  the  afternoon  of  December  19,  and  on  January  7 
was  completely  well  and  continues  well  today,  four  months  after 
the  inoculation. 

Control. — On  the  same  day  monkey  2  (Macacus  rhesus)  was 
injected  intracerebrally  with  0.5  c.c.  of  the  same  suspension  of  the 
same  virus.  This  animal  died  in  convulsions  within  six  days  and 
six  hours.  Histopathological  lesions  were  characteristic  of  polio- 
myelitis. 

Normal  Horse  Serum  and  Normal  Human  Serum. — Various 
observers  have  suggested  the  use  of  either  normal  serum  or  normal 
horse  serum  by  intraspinal  injection.  Some  experiences  with  this 
method  are  detailed  by  Sophian.^  Both  normal  horse  serum  and 
normal  human  serum  can  easily  be  procured,  and,  if  sterile  and 
properly  injected,  are  probably  harmless.  In  order  to  avoid  sensiti- 
zation to  a  foreign  protein  it  seems  preferable  to  use  human  serum. 
Horse  serum  when  injected  into  the  spinal  canal  seems  to  cause 
a  hyperleukocytosis  which  he  believes  to  be  of  very  definite  value. 
He  used  this  method  with  horse  serum  on  a  series  of  10  patients, 
mostly  cases  admitted  late,  and  believes  that  in  the  few  cases  in 
which  it  was  used  early  some  definite  improvement  was  noted^  The 
changes  in  the  cerebrospinal  fluid  after  the  injection  of  the  serum 
consist  in  a  definite  increase  in  the  polynuclear  cells  and  a  very 
high  cell  count  within  eighteen  hours,  quite  striking  from  the 
number  of  lymphocytes  usually  seen.  Twenty-four  hours  after  the 
injection  the  fluid  becomes  faintly  opalescent,  occasionally  turbid, 
but  examination  shows  a  sterile  fluid  like  that  seen  in  aseptic  menin- 
gitis. He  also  treated  a  small  series  of  10  cases  with  serum  from 
convalescent  patients,  and  in  some  he  thought  he  obtained  favorable 
results,  but  not  better  than  in  those  cases  in  which  normal  horse 
serum  was  used.     (See  the  Virus  and  the  Choroid  Plexus.) 

1  Jour.  Am.  Med.  Assn.,  August  5,  1916,  p.  426. 


ACUTE  STAGE  <  175 

Svv,vi(in/  of  Serum  Treatment.- — Immune  serum,  normal  human 
serum,  or  sterile  horse  serum  may  be  used.  The  exact  value  of 
these  cannot  be  stated  at  the  present  time.  AYe  believe,  howe\er, 
that  one  is  justified  in  doubting  both  the  efficacy  or  the  advisability 
of  the  use  of  horse  serum  or  of  normal  human  serum.  From  the 
evidence  at  hand  we  do  not  believe  that  the  immune  serum,  as  used 
at  present,  "will  be  found  to  be  of  any  value  in  the  frankly  paralyzed 
cases,  certainly  not  unless  used  at  the  onset  of  the  loss  of  power. 
In  progressi^■e  cases  and  those  with  threatened  respiratory  involve- 
ment the  serum  might  be  tried.  In  the  preparalytic  cases  the  results 
seem  more  encouraging,  but  until  larger  series  of  treated  and  non- 
treated  cases  are  compared,  it  is  impossible  to  say  more  at  this  time. 
If  a  definite  diagnosis  has  been  made  and  the  serum  is  at  hand,  we 
ad\ise  its  use,  but  would  not  consider  the  failure  to  use  it  as  a  serious 
omission  in  the  treatment.  Antipoliomyelitic  horse  serum  may  be 
used  in  place  of  the  human  serum  if  available.     (See  same.) 

Autotherapy. — Duncan^  has  suggested  the  use  of  the  cerebro- 
spinal fluid  withdrawn  from  the  patient  himself  and  injected  into  the 
tissues:  1  c.c.  or  less  doses.  We  would  not  recommend  this  method 
of  treatment  at  the  present  time.  It  has  also  been  suggested  that 
the  blood  be  withdrawn  from  the  patient's  vein  and  the  serum  used 
intraspinally,  a  procedure  which  we  deem  of  very  doubtful  value 
without  having  any  definite  information  concerning  it. 

Epinephrin  or  Adrenalin  Treatment. — INIeltzer-  has  given  an  account 
of  the  use  of  this  treatment  with  certain  suggestions  regarding  its 
applications  in  human  beings.  He  calls  attention  to  the  differences 
between  the  inflammatory  focus  and  the  inflammatory  area  in 
poliomyelitis,  just  as  it  may  occur  in  other  inflammatory  diseases. 
He  gives  his  experience  with  the  use  of  artificial  respiration  in 
monkeys  dying  from  the  disease.  In  his  studies  he  concluded  that  in 
cases  in  which  there  was  an  ascending  paralysis  death  is  due  to  a 
respiratory  paralysis  from  an  involvement  of  the  centers  of  the  chief 
respiratory  nerves,  while  in  cases  of  encephalitic  poliomyelitis  the 
vasomotor  center  may  be  the  first  to  become  paralyzed  and  death  is 
due  primarily  to  a  rapid  sinking  of  the  blood-pressiu'e.  As  had 
been  pointed  out  by  Peabody,  Draper  and  Dochez  the  three  facts 
in  the  acute  pathology  of  the  disease  consisted  of  a  cellular  exudate, 
hemorrhage,  and  edema,  which  may  be  regarded  as  the  primary 
reaction  of  the  nervous  system  to  the  virus  of  the  disease,  and  from 

1  New  York  iNIed.  Jour.,  August  19,  1916,  p.  342.  =  ihjd. 


176  TREATMENT 

this  come  changes  which  result  in  part  from  direct  pressure  on  the 
nerve  cells.  Without  going  into  Meltzer's  arguments  more  fully 
it  may  be  said  that  he  believes  that  if  you  can  find  a  means  by  which 
edema  and  other  processes  occurring  in  the  inflamed  zone  can  be 
kept  down,  the  nerve  tissues  so  affected  ought  to  derive  a  definite 
benefit.  In  the  use  of  adrenalin  we  have  an  agent  which,  when 
applied  to  inflamed  areas,  will  lessen  congestion  temporarily. 

Clark  used  this  drug  in  some  observations  on  monkeys,  but 
only  animals  that  were  already  extensively  paralyzed  or  moribund 
when  treated.  Animals  so  treated  seemed  to  show  a  very  definite 
improvement  for  a  time,  although  they  eventually  died.  This 
method  of  treatment  was  used  in  over  70  cases  at  the  New  York 
Throat,  Nose  and  Lung  Hospital,  and  the  results  are  given  below. 

The  technic  of  administration  consists  of  injecting  intraspinally 
2  c.c.  of  a  1  to  1000  solution  of  adrenalin,  and  this  is  to  be  repeated 
every  four  to  six  hours.  Before  the  first  injection  is  given  a  fairly 
large  quantity  of  spinal  fluid  should  be  withdrawn,  the  amount  being 
in  proportion  to  the  pressure  prevailing  in  the  spinal  canal.  The 
subsequent  injections  should  be  made  without  regard  to  the  presence 
or  absence  of  spinal  fluid,  and  unless  the  pressure  appears  to  be  very 
high,  not  much  of  the  spinal  fluid  should  be  withdrawn,  because  at 
this  stage  the  spinal  fluid  may  contain  some  valuable  antibodies. 
All  injections  should  be  washed  in  with  2  c.c.  of  normal  salt  solution, 
but  if  no  spinal  fluid  is  present  at  least  5  or  6  c.c.  of  salt  solution 
should  be  used. 

In  this  connection^  he  has  a  short  note,  in  which  he  states  that 
more  than  50  babies  received  an  intraspinal  injection  of  a  1  to  1000 
adrenalin  chloride  solution  every  six  hours  from  the  very  beginning 
of  the  disease,  that  is,  as  soon  as  the  patients  were  brought  to  the 
hospital.  All  of  the  patients  stood  the  2  c.c.  of  adrenalin  intra- 
spinally for  many  days  without  the  slightest  harm. 

Lewis-  has  reported  77  cases  in  which  adrenalin  was  used.  He 
suggests  getting  rid  of  the  0.5  per  cent,  of  chloret'one  that  is  in 
the  1  to  1000  adrenalin  solution  by  removing  the  stopper  from  the 
bottle  and  placing  it  in  a  bath  of  boiling  water  for  two  or  three 
minutes.  The  solution  is  then  allowed  to  cool,  and  he  suggests  that 
the  injections  be  made  without  diluting  the  adrenalin  with  anything. 
A  fresh  preparation  must  be  used  at  each  administration.  Eighteen 
of  the  patients  died,  but  most  of  these  cases  were  in  children  who 

1  Jour.  Am.  Med.  Assn.,  August  5,  1916,  p.  461. 

2  Med.  Record,  September  23,  1916,  p.  541. 


CONVALESCENT  STAGE  177 

were  moribund  or  who  died  from  other  conditions.  Only  o  could 
be  considered  to  ha\'e  had  a  fair  cliance  under  the  treatment.  Of 
those  that  recoxered  21  showed  complete  recovery,  21  were  greatly 
improved,  and  at  the  time  of  the  report  it  was  supposed  that  more 
or  less  complete  recovery  would  follow,  and  17  showed  disability 
that  would  probably  be  permanent.  The  results  of  its  use  in  the 
New  York  epidemic  were,  on  the  whole,  such  as  to  lead  the  report 
of  the  Health  Department  to  declare  it  without  value.  We  believe, 
however,  that  the  rapidly  progressive  cases  and  those  with  threat- 
ened or  developed  respiratory  paralysis  that  it  should  be  given  a 
more  extended  trial.    We  do  not  advise  its  use  in  ordinarv  cases. 


THE  CONVALESCENT  STAGE. 

This  is  usually  reckoned  from  the  end  of  the  tenderness  to  the 
end  of  two  years.  During  this  period  the  child  should  be  under 
observation  and  seen  at  sufficiently  close  interx-als  to  prevent  the 
development  of  any  deformity  and  to  supervise  the  restoration  of 
function.  The  question  of  when  to  get  the  child  up  out  of  bed  is  a 
very  important  one,  and  there  are  some  differences  of  opinion.  As 
soon  as  the  pain  and  tenderness  have  disappeared  the  child  should 
be  gotten  up  as  soon  as  possible.  It  will  depend  very  largely  on  the 
extent  of  the  paralysis  how  soon  this  will  be  feasible.  From  four  to 
eight  weeks  are  ordinary  periods  of  complete  rest  in  bed.  After 
it  is  allowed  up  the  child  should  never  be  allowed  to  fatigue  itself, 
either  locally  or  generally,  and  this  is  a  point  on  which  we  have 
insisted  in  various  places.  Reasons  for  getting  the  child  up  are 
many.  In  the  first  place  the  normal  child  is  a  very  active  being, 
and  nutrition  is  better  and  the  child  is  healthier  and  happier  and 
will  develop  mentally  better  if  it  is  about;  and  it  also  permits  a 
child  being  in  the  fresh  air  in  many  instances  when  it  would  not  be 
possible  otherwise.  It  has  the  additional  advantage  that  the  shorter 
time  the  child  is  kept  at  rest  in  bed  the  less  trouble  it  will  have  in 
regaining  its  power  to  balance  itself,  all  other  things  being  equal. 
In  the  patients  who  are  not  able  to  walk  or  even  stand  the  first  care 
is  to  try  to  have  the  child  propped  up  in  bed  so  that  he  can  sit  up, 
care  being  taken,  as  far  as  it  is  humanly  possible,  to  prevent  deform- 
ities of  the  back,  and,  if  necessary  a  properly  fitting  corset  may  be 
made  to  assist  the  weakened  muscles.  If  the  child  is  so  paralyzed 
that  he  can  neither  walk  nor  stand  alone  it  will  be  necessary  to 
furnish  sufficient  amount  of  support  by  the  use  of  braces.  If  neces- 
12 


178  TREATMENT 

sary,  there  may  be  a  combination  of  properly  fitting  corset  and 
braces  used  at  the  same  time.  Astonishing  results  can  sometimes 
be  obtained  even  in  cases  in  which  the  outlook  does  not  seem  very 
favorable.  Usually  the  first  thing  that  is  to  be  undertaken  is  to 
teach  the  child  how  to  stand.  With  the  added  weight  of  the  brace 
this  may  require  some  little  time  and  patience.  The  child  may  be 
held  under  the  arms  or  he  may  be  supported  by  having  a  suitable 
frame  to  brace  the  body,  or  he  may  be  stood  up  against  a  board  and 
supported  by  a  band  under  the  arms.  Gradually  the  new  supports 
will  become  natural,  and  as  soon  as  the  standing  is  accomplished, 
with  the  aid  of  very  little  support,  attempts  may  be  made  to  teach 
the  child  how  to  balance  himself.  This  is  done  by  the  use  of  crutches 
and  whatever  assistance  may  be  necessary,  or  in  some  cases  may  be 
done  by  holding  the  child  under  the  arms  while  he  recovers  the  sense 
of  equilibrium.  This,  in  many  instances,  does  not  seem  to  be  entirely 
associated  with  the  loss  of  power,  and  in  the  rare  ataxic  cases 
may  be  an  almost  insuperable  obstacle  to  teach  the  child  to  walk. 
As  soon  as  the  child  can  balance  himself,  walking  may  be  taught, 
and  in  the  slight  cases  this  is  usually  accomplished  very  quickly, 
the  child  becoming  accustomed  to  new  conditions  with  remark- 
able ease.  In  cases  in  which  both  legs  are  very  badly  paralyzed, 
the  child  has  to  learn  to  walk  with  crutches,  and  this  may  be  an 
exceedingly  difficult  undertaking.  The  mode  of  walking  will  depend 
largely  on  the  extent  of  the  paralysis.  If  possible,  the  child  should 
be  taught  to  move  one  foot  forward  after  the  other,  using  the 
crutches  as  an  added  support  and  balance.  In  the  more  severe 
cases  this  method  will  not  suffice,  and  the  child  will  have  to  be 
taught  to  support  himself  on  the  crutches  and  to  advance  them  so 
that  the  body  is  now  supported  on  three  points,  the  legs  at  the  rear 
and  the  crutches  to  either  side  forward.  The  legs  may  now  be 
dragged  up  to  where  the  crutches  are  and  the  crutches  again 
extended.  This  is  the  most  difficult  part  of  the  procedure  and  many 
times  the  little  patients  lose  their  balance  and  fall.  This  may  be 
obviated  to  a  certain  extent  by  having  one  leg  left  somewhat  behind 
the  other  so  that  the  body  will  have  three  points  of  support  when 
the  attempt  may  be  made  to  advance  the  crutches  and  then  bring 
up  the  leg  that  is  farthest  behind.  In  the  very  bad  cases  the  child 
will  not  be  able  to  move  the  legs  independently,  but  often  will  be 
able  to  get  about  surprisingly  well  by  swinging  the  body  on  the 
crutches.  Efforts  should  always  be  made,  however,  to  teach  the 
child  to  move  the  legs  one  after  the  other,  and  in  many  instances 


CONVALESCENT  STAGE  179 

by  prolonged  training  the  child  may  learn  to  walk,  even  with  more 
or  less  complete  paralysis  of  the  legs,  by  twisting  the  pelvis  from  side 
to  side,  so  moving  one  leg  forward  after  the  other. 

In  considering  hospital  cases  the  method  of  procedure  used  by 
the  hospitals  under  the  New  York  Board  of  Health  during  the 
epidemic  of  191G  is  interesting.  After  five  weeks  had  elapsed  the 
cases  were  studied  with  a  view  to  what  further  treatment  would  be 
necessary.  Out  of  1707  cases  the  results  of  the  treatment  used  when 
the  patient  was  discharged  from  the  hospital  was  as  follows:  In 
6  cases  the  patients  had  extreme  paralysis,  were  unable  to  hold  the 
body  erect,  and  there  was  no  possible  chance  for  ambulatory  treat- 
ment. These  cases  were  either  given  plaster  supports  and  kept  under 
observation  or  the  hospital  care  was  continued,  the  latter,  of  course, 
being  the  best  method  of  procedure  where  it  is  possible.  The  second 
class  of  cases,  consisting  of  1443,  had  a  slight  paralysis  or  weakness, 
but  there  w-as  evidence  of  rapidly  returning  power.  These  children 
were  fitted  with  temporary  plaster  splints  and  kept  under  super- 
vision. The  third  class,  consisting  of  9  cases,  showed  no  signs  of 
returning  power  and  were  regarded  as  permanently  paralyzed. 
These  children  were  supplied  with  suitable  braces  and  with  crutches 
w^hen  they  were  needed.  The  fourth  class  of  cases,  numbering  249, 
had  a  marked  paralysis,  but  there  were  some  signs  of  returning 
power,  but  it  was  very  probable  that  recovery  would  take  either 
months  or  one  or  two  years.  In  these  cases  the  patients  were 
furnished  with  less  expensive  braces  and  those  under  one  year  of 
age  were  put  up  in  suitable  light  plaster  casts. 

Prevention  of  Deformity. — Of  the  utmost  importance  during  the 
first  few  weeks  is  the  prevention  of  contraction  of  the  muscles  with 
the  consequent  deformities.  These  often  come  on  very  early  and 
can,  in  a  very  large  majority,  be  prevented.  The  advantage  of 
proper  treatment  is  that  the  tendons  and  muscles  are  not  allowed 
to  stretch  out  of  their  normal  positions.  The  commonest  deformity 
is  the  foot-drop  and  toe-drop,  but  there  may  be  contractions  of 
the  leg  on  the  thigh  and  other  deformities  that  are  very  apparent 
on  examining  the  patient.  INIany  simple  devices  have  been  sug- 
gested, and  it  does  not  make  very  much  difference  what  is  used  as 
long  as  it  is  found  effective.  The  foot,  for  example,  should  be 
placed  at  the  right  angle  to  the  leg  and  held  in  this  position,  either 
by  a  cast  of  plaster  of  Paris,  which  should  be  cut  open  at  the  end 
of  a  week  or  ten  days  enough  to  allow  the  proper  care  of  the  leg,  or 
a  right-angle  splint  made  of  wood  or  tin,  or  the  deformity  may  be 


180  TREATMENT 

overcome  by  the  ingenuous  application  of  adhesive  plaster.  Curva- 
ture of  the  spine  is  difHcult  to  manage  in  the  early  stage,  but  as  far 
as  possible,  and  consistent  with  the  amount  of  pain  and  the  irri- 
tability of  the  patient,  attempts  should  be  made  to  keep  the  patient 
in  a  position  that  prevents  a  deformity  of  the  spine.    This  is  very 


Fig.  59. — Paralysis  of  left  arm  and  right  leg.     Shows  a  simple  appliance  for 
preventing  foot-drop. 

much  more  easily  said  than  done,  and  it  may  be  necessary,  on 
account  of  the  tenderness,  to  do  very  little  and  use  some  other 
treatment  to  correct  the  condition  later  on. 

Fatigue. — It  should  be  remembered  that  while  a  muscle  may 
atrophy  from  non-use  that  it  may  also  atrophy  from  too  much  use. 
This  latter  is  well  exemplified  in  the  various  atrophies  due  to  occupa- 


CONVALESCENT  STAGE  181 

tlon,  such  as  that  seen  in  the  hands  of  tailors.  An  atrophy  from 
fatigue  seems  particuhirly  Hable  to  happen  when  the  nerves  and 
muscles  have  been  affected  by  poliomyelitis.  Whoever  is  taking 
care  of  the  child  should  be  particularly  warned  to  use  the  best 
possible  care,  and  it  is  better  to  give  too  little  exercise  rather  than 
too  much,  and  the  same  is  certainly  true  of  both  massage  and 
electricity.  Lovett  has  suggested  the  use  of  the  spring-balance 
test,  and  if  a  muscle  is  getting  worse  instead  of  better  in  its  capacity 
to  work,  as  shown  by  the  amount  of  pull  that  can  be  made,  the 
treatments  should  be  diminished  to  allow  the  muscles  a  greater 
amount  of  rest. 

Hydrotherapy. — ^This  is  of  very  great  value  and  may  be  used 
for  two  different  things.  In  the  first  place  hot  baths  continued  for 
ten  to  fifteen  minutes  or  even  half  an  hour,  and,  in  some  cases,  even 
longer,  may  be  used  for  the  relief  of  persistent  pain  and  tenderness, 
and  in  many  cases  has  a  most  beneficial  eflect.  It  may  also  be  used 
as  an  aid  in  exercising  muscles  that  are  very  weak.  The  child  is 
placed  in  a  warm  bath,  the  weight  of  the  limb  in  the  water  is  very 
much  less  than  it  would  be  in  the  air,  and  the  child  can  often  move  a 
paralyzed  extremity  in  this  way  when  it  would  be  impossible  to  do 
so  under  ordinary  conditions.  After  the  acute  stage  is  past  the 
child  may  be  placed  in  a  warm  bath  every  day  and  allowed  to 
exercise  the  affected  parts  under  careful  supervision.  Here,  as  else- 
where, great  care  should  be  taken  to  prevent  fatigue. 

Under  this  heading  the  use  of  enemas  for  the  prevention  of 
constipation  may  be  mentioned. 

Massage. — This  is  one  of  the  most  valuable  means  we  have  of 
treating  the  paralyzed  cases,  and  it  is  to  be  highly  recommended. 
The  best  results  are  obtained  by  trained  operators,  but  a  sufficient 
amount  may  easily  be  taught  anyone  of  average  intelligence.  The 
advantage  of  massage  is  that  it  exercises  the  muscles  and  so  directly 
stimulates  nutrition,  and  also  causes  an  increased  flow  of  blood  and 
lymph  to  the  affected  part  and  increases  the  flow  of  Ijniph  and  flow 
of  blood  away  from  the  muscles,  so  carrying  oft'  the  products  of 
metabolism  more  rapidly  than  would  be  the  case  without  it.  It  is 
of  great  service  in  overcoming  the  malnutrition  and  lack  of  growth 
of  the  paralyzed  extremities,  but  too  great  results  should  not  be 
expected  of  it  in  this  connection.  The  manipulation  should  consist 
(1)  of  stroking  movements  and  should,  as  far  as  possible,  be  from 
below  upward  so  as  to  facilitate  the  Ij'mph  flow,  and  then  may  be 
followed  by  kneading  motions,  the  muscle  or  muscle  group  being 


182  TREATMENT 

rolled  between  the  thumb  and  fingers  so  that  the  muscle  itself  is 
manipulated  and  not  merely  the  skin,  and  (2)  the  muscles  may  be 
gently  patted,  care  being  taken  not  to  produce  any  pain  or  dis- 
comfort. It  is  very  important  that  the  treatment  should  not  be 
continued  too  long  and  the  manipulations  should  be  much  more 
gentle  in  younger  children  than  that  indicated  in  older  children  or 
adults.  Overuse  of  massage  brings  about  a  lack  of  muscle  tone  and 
the  overfatigue  of  the  muscles  probably  helps  to  make  it  atrophy. 

Professional  operators  who  have  not  had  experience  with  children 
should  be  particularly  cautioned  on  this  point.  The  length  of  time 
for  the  treatment  may  vary  with  the  age  and  condition  of  the  child. 
With  grown  people  recovered  to  reasonable  robustness  of  health 
an  hour  may  be  taken  to  go  over  the  entire  body.  Half  this 
time  should  suffice  for  half-grown  children,  and  younger  children 
should  be  massaged  from  five  to  twenty  minutes,  always  stopping 
if  there  is  any  sign  of  the  child's  getting  irritated  or  showing  fatigue. 
The  massage  may  be  combined  with  muscle  training  and  exercise, 
and  may  often  be  given  in  a  warm  bath,  which  tends  to  increase  the 
flow  of  blood  and  make  the  exercises  much  more  easy.  In  using 
massage  apart  from  the  warm  bath  it  is  advisable  to  warm  the 
affected  part  first  by  applications  of  hot  towels  (see  Heat),  and 
after  the  treatment  the  body  should  be  carefully  protected  until  the 
circulation  has  returned  to  normal.  Mechanical  vibrators  may  be 
used  to  great  advantage,  care  being  taken  that  the  vibration  is  not 
too  strong.    It  should  not  produce  any  unpleasant  effects. 

Heat. — Heat  may  be  used  in  connection  with  massage  and  a 
preliminary  hot-air  bath  may  be  given,  either  to  the  whole  body 
or  to  the  affected  part,  preferably  before  using  massage.  The 
heated  muscle  acts  more  easily,  the  artificial  taking  the  place,  to 
a  certain  extent,  of  the  warming-up  process  used  by  athletes,  and 
it  probably  also  acts  by  increasing  the  amount  of  blood  flow  to  the 
heated  part.  If  dry  heat  is  used  some  of  the  simple  forms  of 
apparatus  may  be  employed,  and  if  expense  is  no  object  a  suitable 
simple  apparatus  with  electric-light  bulbs  with  carbon  filaments 
may  be  easily  constructed,  either  big  enough  for  the  entire  body  or 
for  one  extremity.  A  simple  method  consists  of  using  some  of  the 
electric  heating  pads,  especially  when  the  part  that  is  to  be  warmed 
is  not  too  large  or  the  parts  can  be  heated  by  applying  hot  wet  towels. 
Moist  heat  cannot  be  used  in  as  high  temperature  as  dry  heat,  and 
in  some  people  has  a  tendency  to  produce  a  tenderness  of  the  skin. 
The  heating  process  may  be  carried  over  from  three  to  fifteen  min- 


CONVALESCENT  STAGE  183 

utes  and  the  temperature  may  be  as  high  as  the  patient  can  stand 
without  discomfort.  The  paralyzed  extremities  should  always  be 
kept  warm  by  proper  clothing  and  in  cold  climates  and  in  winter, 
woolen  underwear  and  stockings  and  gloves  are  to  be  recommended. 
If  the  child  is  unable  to  move  about  great  care  should  be  taken  to 
see  that  it  is  kept  properly  warm,  using  artificial  heat,  such  as  a 
hot-water  bag,  should  it  be  found  necessary. 

Treatment  by  Electricity. — In  former  days  electricity  was  used 
as  almost  the  only  means  of  treating  the  paralysis  resulting  from 
poliomyelitis.  Often  the  patient  was  supplied  with  a  small  faradic 
battery  and  generally  allowed  to  use  it  haphazard  without  much 
instruction.  Personally,  we  have  had  but  comparatively  little 
experience,  but  we  do  not  believe  that  electricity  has  a  very  high 
place  in  the  therapy  of  poliomyelitis — at  any  rate,  not  as  used 
at  the  present  time.  Careful  obser\'ations  by  certain  physicians, 
notably  Lovett,  seem  to  show  pretty  conclusively  that  electricity 
possesses  no  specific  value.  Electricity  may  be  used  to  produce 
muscular  contractions,  even  if  voluntary  exercise  is  impossible,  and 
it  may  promote  chemical  changes  in  the  muscles  and  so  aid  in 
muscle  nutrition  and  growth.  It  seems,  however,  that  in  the  main 
electricity  does  nothing  that  skilful  massage  will  not  do.  One  could 
readily  imagine  considerable  harm  being  done  by  the  indiscriminate 
use  and  overdosage  in  the  hands  of  a  mother  or  nurse  who  is 
under  the  impression  that  the  battery  contains  some  occult  power. 

Either  the  galvanic  or  faradic  current  may  be  used.  It  is  impor- 
tant that  the  confidence  of  the  patient,  especially  if  it  is  a  young 
child,  should  be  gained  before  any  attempt  is  made  to  give  electrical 
treatment,  and  it  may  be  advisable  to  apply  the  electrodes  for 
several  days  without  passing  any  current  through  them  in  order  to 
reassure  the  child.  A  very  weak  current  may  be  used  at  the  outset 
and  gradually  made  stronger,  and  may  be  increased  to  the  amount 
giving  a  good  contraction  of  the  muscles.  If  the  faradic  current  is 
applied  to  a  muscle  that  will  contract  to  this  current  it  is  best  to 
apply  one  of  the  electrodes  at  the  motor  point  as  described  by  Erb. 
If  the  muscle  does  not  contract  to  this  current  there  is  no  use  in 
using  it.  The  length  of  the  treatment  should  be  limited,  not  more 
than  ten  to  fifteen  minutes  for  going  over  an  extensively  paralyzed 
child,  and  only  a  few  contractions  for  each  particular  muscle  or 
muscle  group.  As  a  rule  faradic  current  is  not  well  borne  by 
children,  and  it  may  be  impossible  to  use  it.  In  e^■ery  instance 
the  current  should  be  passed  through  the  operator's  body  before 


184  TREATMENT 

trying  it  on  the  child.  The  faradic  current  may  be  used  to  contract 
the  muscle  best  by  placing  the  positive  pole  or  anode  over  the 
muscle  which  one  wishes  to  stimulate  and  the  negative  pole  or 
kathode  either  a  short  distance  away  or  over  the  spine.  Each 
muscle  may  be  contracted  several  times  by  opening  and  closing  the 
current.  Little  or  nothing  is  known  about  the  effect  of  some  of 
the  newer  forms  of  currents,  and  we  have  no  information  of  any 
value  regarding  the  high  frequency,  the  Morton  wave,  or  the 
sinusoidal  current. 


CHAPTER    XIII. 
ORTHOPEDIC  TREATMENT. 

The  fitting  of  braces  to  a  paralyzed  child  is  a  matter  that  should 
be  left  to  an  orthopedic  specialist  when  this  is  possible.  The  best 
results  are  only  to  be  obtained  by  having  the  proper  support  pre- 
scribed by  someone  whose  daily  work  gives  him  a  clearer  insight 
into  the  mechanical  structure  and  possibilities  of  the  many  braces 
and  splints  used  in  orthopedic  treatment.  Wherever  it  is  possible 
the  child  should  be  sent  to  one  of  the  many  excellent  orthopedic 
institutions  if  the  parents  are  unable  to  pay  for  expert  care,  or  if 
the  child  is  situated  in  a  place  where  there  is  no  competent  ortho- 
pedic surgeon.  A  great  deal  of  time  and  trouble  will  be  saved  by 
this  method.  There  are  no  inherent  difficulties  in  learning  to 
prescribe  the  proper  forms  of  support,  but  it  takes  someone  with 
a  somewhat  mechanical  turn  of  mind  and  a  very  thorough  knowl- 
edge of  what  is  desired  to  be  accomplished.  There  are  a  very  great 
number  of  different  forms  of  splints  and  braces  that  have  been 
designed  for  the  various  forms  of  paralysis  and  deformity.  The 
brace  may  need  subsequent  adjustment  and  modification,  and  as  the 
child  grows  or  improves  changes  may  be  needed.  A  considerable 
damage  may  be  done  by  one  who  is  not  familiar  with  the  construc- 
tion of  the  various  appliances  and  the  use  to  which  they  are  put. 
Braces  and  splints  may  be  used  for  a  great  number  of  different 
purposes.  Their  chief  uses  are  (a)  support  for  weakened  or  paralyzed 
limbs;  (b)  to  prevent  deformity  by  maintaining  parts  above  and 
below  a  joint  in  their  proper  relation  to  each  other;  (c)  to  prevent 
contracture  of  non-paralyzed  muscles;  (d)  to  prevent  overstretch- 
ing of  the  partially  paralyzed  muscles. 

By  preventing  overstretching  of  paralyzed  muscles  and  by  holding 
affected  limbs  in  the  best  possible  position  for  the  partially  paralyzed 
muscles  to  functionate — they  aid  directly  in  the  recovery  from  the 
paralysis.  They  are  used  to  aid  in  the  correction  of  existing  deformi- 
ties in  conjunction  with  other  treatment.  In  other  instances  they 
may  be  applied  as  a  matter  of  support  to  aid  in  the  patient's  walking 
and  they  are  also  used  for  the  fixation  of  flail-joints.  They  also 
assist  in  maintaining  the  muscular  balance  and  aid  in  lessening  the 


186  ORTHOPEDIC  TREATMENT 

muscular  strain  and  stretching  of  the  group  of  muscles  which  are 
paralyzed.  The  simpler  the  splint  is  in  construction  the  better  it  is 
apt  to  serve  its  purpose  and  it  should  be  as  light  in  weight  as  is  con- 
sistent with  the  function  that  it  is  to  perform.  In  children  who 
are  not  going  to  need  the  aid  of  a  brace  but  for  a  few  months,  one 
of  inexpensive  material  and  make  is  to  be  preferred.  The  same  is 
true  where  there  is  any  reason  to  believe  that  the  brace  is  going  to 
be  changed  in  a  comparatively  shori  time.  In  patients  in  whom 
the  brace  is  to  be  a  more  or  less  permanent  factor,  or  to  be  used  for 
a  long  period  of  time  a  very  much  greater  amount  of  care  should  be 
used  in  the  workmanship  and  in  the  material,  but  in  no  case  should 
the  expense  be  considered  to  such  an  extent  as  to  defeat  the  purposes 
for  which  the  brace  is  intended.  It  must  always  be  borne  in  mind 
that  a  splint  or  brace  must  fit  the  paralyzed  member  snugly,  but  it 
must  not  be  too  tight.  Any  sort  of  apparatus  which  interferes  with 
the  circulation  or  causes  pressure  in  any  way  or  which  chafes  the 
patient  is  apt  to  be  rather  a  detriment  than  a  benefit. 

The  braces  are  usually  made  out  of  iron  or  steel  bands  or  bars  and 
are,  in  most  instances,  attached  to  the  shoes  when  used  for  the 
lower  extremities.  In  practically  all  cases  the  shoe  forms  a  very 
important  part  of  the  apparatus  and  grf^at  care  should  be  taken  in 
selecting  a  shoe  that  fits  properly  and  is  comfortable.  The  braces 
are  supported  above  by  additional  bands  or  by  straps  with  buckles. 
In  the  adjustment  of  the  straps  and  bands  it  is  very  important 
that  there  is  no  undue  pressure  at  any  point  and  that  they  do  not 
permit  undue  rubbing  of  the  skin.  The  braces  should  be  inspected 
from  time  to  time  to  see  that  this  is  not  taking  place.  If  the  appa- 
ratus is  to  be  worn  constantly  it  should  be  removed  daily,  where  this 
is  possible,  to  care  for  the  skin.  The  chief  use  of  braces  is  in  the 
question  of  walking,  for  support  and  in  the  prevention  of  deformities 
and  stretching  of  muscles.  For  other  purposes  and  in  most  instances 
plaster  casts  are  used.  A  splint  very  frequently  is  needed  for  the 
treatment  of  paralysis  of  the  anterior  thigh  muscles  and  for  this 
purpose  either  the  caliper  splint  or  the  paralytic  brace,  is  generally 
used.  The  nature  of  these  braces  is  very  well  shown  in  the  illustra- 
tions. The  caliper  splint  is  made  of  two  iron  or  steel  bars  without 
joints  running  up  the  leg  and  thigh,  one  on  either  side  to  a  padded 
ring  which  passes  obliquely  around  the  thigh  at  the  level  of  the 
groin,  the  inner  portion  of  the  ring  resting  against  the  tuberosity  of 
the  ischium,  and  the  outer  portion  a  little  above  the  greater 
trochanter.    The  lower  ends  of  the  uprights  are  turned  inward  at  a 


SHORTENING  1<S7 

right  angle  and  slotted  in  the  heel  of  the  shoo.  Tlie  uprights  may 
each  be  made  in  two  pieces  connected  by  a  slot  and  screws,  so  that 
the  length  may  be  adjusted.  Leather  and  steel  lacing  bands  are 
attached  to  the  uprights  at  the  level  of  the  calf  and  middle  of  the 
thigh.  Between  the  thigh  and  calf  bands  the  knee  may  be  bandaged 
with  a  flannel  bandage  or  a  leather  knee  cap  may  be  used  to  support 
the  knee. 

Paralytic  Brace. — The  brace  most  frequently  used  for  paralysis 
of  the  lower  limbs  involving  the  muscles  controlling  the  hip,  knee 
and  ankle,  or  knee  and  ankle,  is  known  as  the  paralytic  brace.  It 
consists  of  double  steel  uprights  fastened  in  the  shank  of  the  shoe 
and  extending  to  the  upper  third  of  the  thigh,  from  which  point  it 
is  carried  upward  by  an  outside  upright  to  a  pelvic  band.  A  free 
joint  is  made  at  the  level  of  the  hip-joint  a  slip-catch  joint  at  the 
knee  by  which  the  knee  can  be  held  rigid,  or  allow^ed  to  bend 
freely,  and  a  right-angled  stop-catch  joint  at  the  ankle.  The  ankle 
stop-catch  joint  is  made  forward  or  reverse,  depending  upon 
whether  there  is  paralysis  of  the  anterior  leg  muscles  or  calf 
muscles.  With  this  brace  properly  constructed  and  applied  a  patient 
having  paralysis  of  all  muscles  below  the  hip-joint,  except  the  ilio- 
psoas and  without  deformities  at  hip,  knee,  or  ankle,  can  be  made 
to  walk. 

Gastrocnemius  Paralysis. — In  paralysis  of  the  gastrocnemius  the 
patient  is  fitted  with  a  high-heel  shoe  from  a  half  to  an  inch  and  a 
half,  according  to  the  age  and  size  of  the  child.  This  keeps  the 
weight  of  the  body  from  the  affected  part  and  it  is  very  important 
that  the  child  wear  the  shoe  from  the  time  he  gets  out  of  bed  until 
he  gets  into  it  and  should  not  be  allowed  to  wear  slippers  or  go 
barefoot. 

Passive  motion  of  the  ankle  to  the  normal  limits  in  all  directions, 
especially  plantar  flexion,  should  be  practised  daily  to  prevent  con- 
traction of  the  anterior  muscles  of  the  leg  (dorsiflexors  of  the  foot) . 

Shortening. — In  paralysis  of  one  leg  this  is  very  apt  to  occur  and 
causes  very  marked  disturbance  of  gait,  tilting  the  pelvis  in  such  a 
manner  that  practically  all  the  means  of  locomotion  are  working 
at  a  disadvantage.  Various  small  amounts  of  shortening,  under 
half  an  inch,  do  not  interfere  very  seriously  with  walking,  but  if  it 
is  over  this  amount,  the  correction  should  be  made  by  means  of  a 
thick-soled  shoe  or  extension  shoe,  or  some  of  the  other  devices 
according  to  the  extent  of  the  deformity,  and  this  should  be  done 
early,  before  the  patient  has  suffered  from  the  effects  of  walking  with 


188  ORTHOPEDIC  TREATMENT 

the  tilted  pelvis.    This  should  be  done  whether  the  patient  wears 
braces  or  not,  and  also  either  before  or  after  operative  procedures, 

Scoliosis. — Lateral  curvature  of  the  spine  due  to  paralysis  of  the 
group  of  muscles  of  one  side  is  a  difficult  condition  to  prevent  and 
also  to  correct  after  it  has  occurred.    Perhaps  in  all  cases  the  best 


Fig.  60. — Leg  brace,  with  pelvic  band.     Double  uprights.     No  joint  at  knee.     For 
paralysis  of   the   anterior   thigh   and   leg  muscles.     (Whitman.) 

results  are  obtained  by  supporting  the  spine  so  that  the  deformity 
will  not  increase.  If  very  slight  degrees  are  present  that  may  be 
overcome  by  a  tight-fitting  jacket  of  canvas  or  of  leather  made 
after  the  manner  of  a  corset  and  snugly  fitting  by  means  of  laces. 
In  the  cases  in  which  the  more  severe  deformities  have  occurred  the 
patients  are  perhaps  best  treated  by  plaster  jackets.     These  can 


MEASURING  FOR  ORTHOPEDIC  APPARATUS  189 

only  be  properly  applied  by  one  thoroughly  familiar  with  the  use  of 
plaster  casts,  and  by  one  who  is  skilled  in  putting  them  on.  The 
body  must  be  held  over  special  frames  across  which  are  a  number  of 
straps  on  which  the  child  is  placed  face  downward.  The  curvature 
is  then  reduced  as  much  as  possible  and  held  in  the  correct  position 
by  means  of  straps,  after  which  the  plaster  jacket  is  applied  and 
allowed  to  harden.  Cook^  has  devised  a  strap  which  is  applied  after 
the  plaster  has  hardened.  A  large  part  of  the  cast  on  the  concave 
side  is  cut  away  and  the  most  prominent  part  of  the  spine  deformity 
pulled  to  the  other  side  and  forward  by  the  strap.  The  casts  are 
allowed  to  stay  on  varying  lengths  of  time  and  may  have  to  be 
applied  frequently  following  each  advance  in  overcoming  the  deform- 
ity, and  after  the  maximum  results  have  been  obtained  it  is  necessary 
to  w^ear  some  sort  of  supporting  jacket  or  corset  to  prevent  the 
recurrence.  Some  very  extraordinary  results  have  been  obtained  by 
means  of  forcibly  reducing  the  deformity  in  this  manner.- 

MEASURING  FOR  ORTHOPEDIC  APPARATUS. 

The  question  of  orthopedic  apparatus  is  one  of  much  importance, 
especially  to  the  patient,  as  he  is  the  one  to  wear  it,  and  therefore 
comfort  and  fit  are  of  primary  consideration.  In  order  to  obtain 
the  best  results  from  the  use  of  braces  and  splints,  acciu-acy  in 
measurement  and  exactness  in  fitting  are  two  points  which  should 
not  be  treated  lightly.  It  often  falls  to  the  lot  of  the  physician  to 
order  the  correct  splint  for  his  patient  from  the  manufacturer  of 
such  appliances,  and  at  this  time  a  knowledge  of  such  measurements 
and  the  directions  for  taking  them  is  essential.  We  have  compiled 
a  list  of  measurements  for  the  different  apparatus  used,  which  we 
hope  will  facilitate  the  work  and,  at  the  same  time,  be  accurate  in 
its  detail.  It  is  always  essential  to  state  at  the  beginning  of  all 
measurements  seAcral  things  which  apply  to  all  forms  of  apparatus: 

1.  Patient's  name. 

2.  Patient's  age, 

3.  Patient's  weight. 

4.  Patient's  sex. 

5.  Some  description  of  the  case. 

6.  Style  of  apparatus  desired. 

In  taking  measurements  for  the  extremities — feet,  legs,  or  thighs 
— always  state  whether  right  or  left  or  both  sides  are  wanted. 

'  Transactions  of  the  Connecticut  Medical  Society,   1913,  p.   113. 
2  Lovett:  Lateral  Curvatiire  of  the  Spine  and  Round  Shoulders,  1916. 


190 


ORTHOPEDIC  TREATMENT 


The  special  measurements  for  the  different  deformities  are  stated 
below : 

Taliyes  Equinus  and  Calcaneus. — • 

1.  Length  in  inches  from  sole  of  foot  to  ankle, 

2.  "  "               "              "         calf  of  leg. 

3.  Circumference  in  inches  of  calf  of  leg. 

4.  "  "           ankle. 

5.  "  "          instep  of  foot. 

6.  "  "          ball  of  foot. 

7.  Length  in  inches  of  sole  of  foot. 

A.  Ball  of  foot. 

B.  Instep. 

C.  Above  ankle. 

D.  Calf. 

E.  Upper  calf. 

F.  Knee. 

G.  Above  knee. 
H.  Upper  third  of  thigh. 

I.  Thigh  at  perineum. 

K.  Trochanter  major 

L.  Circumference  at  pelvis. 

M.  Circumference  at  umbilicus. 

N.  Forearm  above  wrist. 

0.  Wrist 

P.  Circumference  of  hand. 

Q.  Arm  above  elbow. 

R.  Arm  at  elbow. 

S.  Upper  forearm. 

T.  Middle  forearm. 

U.  Circumference  of  chest. 

V.  Circumference  under  axilla  and  over  shoulder. 

W.  Upper  arm. 

X.  Circumference  of  waist. 

Y.  Lower  third  of  thigh. 

Z.  Circumference  heel  and  instep. 

1.  Sole  of  foot. 
2  to  3.  Length  of  foot. 

4.  Sacrolumbar  articulation. 

5.  First  vertebra  involved  (in  sketch). 

6.  Last  vertebra  involved  (in  sketch). 
7-7.  Centers  of  scapulae. 
8-8.  AxillEB. 

9.  Crest  of  ilium. 

10  to  11.  Extent  of  curvature. 

12.  Circumference  of  head. 

13.  Vertebra  prominens. 

14.  Base  of  skull. 

15.  Leg  below  calf. 

16.  Ankle. 

If  shoes  are  to  be  furnished  for  deformity  apparatus  send  following  measurements: 


Fig.  61. — Diagram  for 
orthopedic  measurements. 
Explanation  of  letters  and 
figures. 


1.  Trace  outUne  of  foot  on  paper 

2.  Length  of  foot  (2  to  3). 

3.  Circumference  above  ankle. 

4.  Circumference  at  ankle. 

5.  Circumference  of  heel  and  instep  (Z). 


6.  Circumference  at  B. 

7.  Circumference  at  A. 

8.  Circumference  at  base  of  little  toe. 

9.  State  if  for  right,  left,  or  both  feet. 


MEASURING  FOR  ORTHOPEDIC  APPARATUS 


191 


For  Genu  Valgus. — 

1.  Circumference  in  inches  of  ankle-joint. 

2.  "  "  knee-joint. 

3.  "  "  calf. 

4.  "  "  thigh  (middle). 

5.  "  "  body  above  iliac  crests  (two  or 

three  inches  above). 

6.  Length  in  inches  from  sole  of  foot  to  ankle-joint. 

7.  "  "  "  "         knee-joint. 

8.  "  "  "  "         hii>joint. 

9.  "  "  "  "  ihac  crests. 


^ 


Figs.  62  and  63. — The  Judson  brace  for  paralysis  of  the  quadriceps  extensor  muscle 
in  connection  with  deformitj^  of  the  foot.      (Whitman.) 

For  Weak  Limbs  due  to  Partial  Paralysis. — 
1.  Circumference  in  inches  of  ankle-joint. 


2. 
3. 
4. 
5. 
6. 
7. 


calf. 

knee-joint. 

thigh. 

pelvis  just  below  iliac  crests. 

ball  of  foot. 

instep. 


8.  Length  in  inches  from  sole  of  foot  to  ankle-joint. 

9.  "  "  "  "  knee-joint. 

10.  "  "  "  "         hip-joint. 

11.  "  "  "  "         iliac  crests. 


192 


ORTHOPEDIC  TREATMENT 


For  Thomas  Hip  Splint. — 

1.  Circumference  in  inches  of  calf. 

2.  "                     "  knee-joint. 

3.  "                      "  lower  third  of  thigh. 

4.  "                      "  upper  third  of  thigh. 

5.  "                     "  crest  of  ilium  (two  inches  below). 

6.  "                     "  chest. 

7.  Length  from  spine  of  scapula  one-third  below  middle  of 
calf  of  leg  taken  posteriorly. 


Fig.  64. — A  brace  for  complete  par- 
alysis of  the  limb,  showing  a  form  of 
lock  at  the  knee  and  a  limited  joint  at 
the  ankle.     (Whitman.) 


Fig.  65. — Anterior  poliomyelitis. 
Paralysis  of  the  anterior  and  pos- 
terior muscles.  Recurvation  of  the 
right  knee.     (Whitman.) 


MEASURING  FOli  ORTHOPEDIC  APPARATUS 


193 


It  is  also  a(lvisal)Ic  to  o})taln  a  drawing  on  paper  of  the  limb  to 
be  fitted,  which  may  be  made  with  patient  staiuh'ng  and  supported. 
It  is  important  for  the  spine  to  be  straight  in  order  to  get  an 
accurate  outhne.  A  lead  strap  which  may  be  molded  to  the  body 
and  then  used  to  make  a  tracing  is  a  great  help. 


Fig.  6G. — Brace  for  complete  paralysis  of  the  anterior  muscles  of  the  limb;  before 
and  after  covering.     (Whitman.) 


Fur  Shoulder  Brace. — 

1.  Circumference  of  body  under  axillae. 

2.  "  "     at  waist. 

3.  "  "     between  iliac  crests  and  trochanter. 

4.  Distance  in  inches  between  lower  border  of  both  scapulae. 

5.  "  "  "        upper  border  of  both  scapulse. 
With  a  piece  of  wire,  mold  exact  form  of  spine  from  cervical  ver- 
tebra (seventh)  to  sacrum  (middle).    Trace  the  shape  on  a  piece  of 
paper. 

13 


194  ORTHOPEDIC   TREATMENT 

For  Anterior  Curvature  of  the  Spine. — 

1.  Circumference  of  waist. 

2.  "  body  under  axillae. 

3.  "  pelvis  between  crests  and  trochanter. 

4.  "  arm  around  shoulder  and  under  axilla. 

5.  Length  in  inches  from  axilla  to  crest  of  ilium  (both  sides). 

6.  "  "  center  of  one  scapula  to  other. 
With  a  piece  of  wire,  mold  shape  of  spine  as  spoken  of  before. 

For  Lateral  and  Posterior  Curvature  of  the  Spine. — 

1.  Circumference  of  chest  under  axillae. 

2.  "  pelvis  between  crests  and  trochanters. 

3.  Length  in  inches  from  axilla  to  crest  of  ilium  (both  sides). 

4.  Length  in  inches  from  center  of  one  scapula  to  the  other. 
5.. Length   in  inches  from   sacrolumbar  articulation   to   first 

vertebra  involved. 

6.  Length   in   inches   from   sacrolumbar   articulation  to   last 

vertebra  involved. 

7.  Length  in  inches  from  sacrolumbar  articulation  to  vertebral 

prominence. 

For  Posterior  Curvature  with  Cervical  Involvement. 

1.  Circumference  of  top  of  head  to  chin. 

2.  "  cranium. 

3.  "  below  iliac  crests  (one  inch). 


CHAPTER     XIV. 
OPERATIVE  TREATMENT. 

All  operations,  whether  they  are  done  to  correct  a  deformity 
or  to  improve  the  function  of  a  part,  should  be  undertaken  only  by 
one  skilled  and  specially  trained  in  orthopedic  surgery.  Operations 
undertaken  by  untrained  surgeons  are  liable  to  be  performed  without 
a  sufficiently  correct  diagnosis  as  to  the  lesion,  and  often  without  a 
very  clear  idea  of  what  is  going  to  result  from  any  given  procedure, 
and  sometimes  results  may  be  obtained  which  militate  very  much 
against  further  operations  of  a  helpful  sort.  At  the  present  time 
there  are  a  large  number  of  excellent  orthopedic  hospitals  and 
clinics  at  which  the  patients  can  easily  secure  attention  or  the 
surgeon  special  training.  It  should  be  borne  in  mind  that  no  opera- 
tive procedure  of  any  kind  should  be  undertaken  until  at  least  two 
years  have  elapsed  from  the  onset  of  the  disease  and  not  until  after 
the  patient  is  at  least  five  years  of  age.  The  reason  for  this  is  that 
under  proper  treatment  many  very  unusual  things  happen,  par- 
ticularly in  the  very  young,  and  an  operation  performed  too  early 
may  be  either  unnecessary  or  will  not  be  suited  to  the  correction 
of  the  deformity  or  the  improvement  of  function  at  a  later  date  after 
the  child  has  grown.  The  first  consideration  is  the  relief  of  the  fixed 
deformity  and,  as  a  general  rule,  if  the  deformity  admits  of  mechan- 
ical treatment,  this  should  be  tried  first  and  very  thoroughly  and  in 
many  instances  the  operation  may  be  avoided.  There  are,  however, 
certain  deformities  which  one  realizes  at  the  start  can  only  be  relieved 
by  operative  procedure.  In  many  instances  where  there  are  con- 
tractions of  the  tendons  and  fascia  relief  may  be  obtained  by  stretch- 
ing the  tissues  and  this  should  be  thoroughly  tried  before  any  cutting 
is  done.  Fasciotomy  or  tenotomy  alone  will  not  often  produce 
satisfactory  permanent  results.  Taylor^  has  given  a  brief  account 
of  the  surgical  treatment  together  with  the  more  important  biblio- 
graphic references. 

The  Equinus  Deformity. — This  is  the  most  common  of  all  deform- 
ities and  is  due  to  the  fact  that  the  foot  is  allowed  to  drop  and  this 

1  New  York  Med.  Jour.,  January  29,  1916,  p.  193. 


196  OPERATIVE   TREATMENT 

is  increased  by  force  of  gravity  aided  by  muscular  contraction  of  non- 
paralyzed  opposing  muscles  and  often  by  the  bedclothes  pressing 
upon  the  toes.    The  foot  being  in  constant  plantar  flexion  allows 
the  posterior  muscles  and  tendons  to  contract,  whereas  those  on  the 
anterior  part  of  the  leg  are  stretched.    This  deformity  may  be  very 
largely  prevented  in  most  cases  by  proper  care  of  the  foot,  which 
should  be  undertaken  from  the  beginning  of  the  disease.    After  it 
has  become  established  it  may  generally  be  relieved  to  greater  or 
less  extent  by  stretching.    Lovett  has  described  a  method  of  treat- 
ment which  will  be  found  easy  of  application  and  to  give  very  satis- 
factory results.    This  consists  of  putting  the  foot  and  leg  up  in  a 
plaster-of-Paris  bandage  from  the  toes  to  just  below  the  knee.    The 
cast  is  applied  while  the  leg  is  fully  flexed  on  the  thigh  in  order  to 
relax  the  gastrocnemius  and  so  permit  of  as  much  dorsal  flexion  as 
possible.     After  the  cast  has  hardened  for  twenty-four  hours  an 
ellipse  is  cut  out  just  in  front  of  the  ankle-joint  and  this  ellipse 
should  go  two-thirds  of  the  way  around  the  cast  at  the  point  where 
it  is  cut.    A  strap  of  webbing  is  placed  around  the  foot  and  another 
high  up  around  the  leg.    These  two  are  then  joined  together  with 
another  webbing  strap  fitted  with  a  buckle.    This  may  be  arranged 
to  pull  either  in  eversion  or  inversion,  as  desired,  and  in  this  way 
a  constant  pull  in  the  proper  direction  may  be  made.     In  the 
moderate  grades  a  deformity  may  often  be  overcome  in  a  week's 
time  and  in  other  cases  two  or  three  weeks  or  even  longer  may  be 
necessary.    In  some  cases  it  may  be  necessary  to  divide  the  tendo- 
Achilles  and  ordinarilya  simple  subcutaneous  operation  is  performed. 
In  other  instances  some  of  the  more  elaborate  tendon-lengthening 
operations  are  preferred,  such  as  Bayer's  plastic  tenotomy.     Care 
should  be  taken  in  selecting  cases  on  which  tenotomy  is  performed, 
and  if  the  anterior  muscles  of  the  leg  are  not  in  fairly  gcod  shape, 
after  the  plaster  cast  is  removed  an  ankle  brace  with  right-angle 
stop-catch  joint   should  be  worn   to  prevent   recurrence.     Some- 
times this  is  prevented  by  the  use  of  an  anterior  silk  ligament.    In 
cases  in  which  the  quadriceps  is  affected,  a  patient  often  gets 
about  better  with  the  equinus  deformity  than  if  it  is  removed,  and 
these  cases  should  also  receive  very  careful  consideration  before 
anything  is  undertaken.    After  the  operation  the  foot  and  leg  are 
put  up  in  a  plaster  cast  at  right  angle  and  the  cast  is  usually  left  on 
about  six  week's  time. 

Knee    Deformities. — Flexion. — This    is    very    often    seen    early, 
and  efforts  should  be  made  to  prevent  its  occurring.    It  may  be 


HIP  DEFORMITIES  197 

the  only  deformity  or  associated  with  flexion  of  the  hip  and  equinus 
deformity.  The  condition  is  best  treated  by  putting  the  leg  in  a 
cast  made  fairly  heavy  over  the  knee  and  then  cutting  the  cast 
for  two-thirds  of  the  circumference  posteriorly  just  behind  the 
knee-joint  and  gradually  separating  the  cast  by  dri\'ing  in  thin 
wedges  of  wood.  This  permits  of  a  gradual  correction  of  the  deform- 
ity, which,  in  mild  cases,  may  be  accomplished  in  a  few  days, 
whereas  in  the  severer  ones  it  may  take  many  wrecks.  The  gradual 
reduction  permits  the  stretching  of  the  contracted  tendons  and 
muscles  and  even  slight  changes  in  the  bones  themselves.  This 
method  is  far  superior  to  the  forcible  reduction  under  an  anesthetic, 
and  in  most  cases  can  be  accomplished  without  tenotomy  of  the 
hamstring  tendons,  but  in  exceptional  cases  this  may  be  necessary. 
Osteotomy  above  the  condyles  in  some  of  the  extreme  cases  may  be 
required,  but  this  should  not  be  undertaken  until  after  the  patient 
has  become  adolescent.  Osteotomy  is  especially  indicated  in  the 
older  and  severe  grades  of  flexion  deformity,  in  conjunction  with 
tenotomy  of  the  hamstring  muscles,  in  order  that  the  deformity 
may  be  corrected  without  too  much  stretching  of  the  popliteal 
nerves,  artery,  and  vein.  In  some  of  the  severer  cases  of  flexion 
of  the  knee,  when  the  flexion  deformity  is  overcome  the  child  will 
be  found  to  be  knock-kneed. 

Hyperextension  of  the  Knee. — This  is  usually  not  very  extensive, 
but  in  neglected  cases  may  reach  the  most  astounding  proportions. 
The  condition  is  best  treated  by  the  use  of  a  caliper  splint  with  a 
posterior  strap  to  prevent  the  hjyperextension  and  this  should  be 
used,  if  necessary,  for  the  prevention  of  it. 

Knock-knees. — This  deformity  is  not  at  all  uncommon  when 
there  has  been  severe  paralysis  of  the  legs.  It  is,  perhaps,  best 
managed  by  use  of  a  splint  along  the  outer  side  of  the  leg  with  a 
leather  band  to  pull  the  knee  outward  to  the  brace.  In  the  worst 
cases  osteotomy  may  be  performed  in  the  same  manner  as  in  cases 
caused  by  rickets. 

Hip  Deformities. — ^There  is  usually  more  or  less  severe  flexion  of 
the  hip,  combined  with  abduction,  and  there  is  usually,  though  not 
always,  flexion  of  the  knee  and  plantar  flexion  of  the  foot  as  well. 
If  the  child  is  able  to  stand,  the  contraction  causes  a  marked  lordosis, 
and  if  it  is  unable  to  stand,  the  leg  cannot  be  brought  down  on  the 
table  without  causing  extreme  lordosis.  Next  to  scoliosis  this  is  the 
most  difficult  deformity  to  overcome.  In  cases  in  young  children 
and  those  of  not  too  long  standing,  stretching  may  be  accomplished 


198  OPERATIVE   TREATMENT 

by  placing  the  patient  on  a  bed  frame  and  then  applying  traction 
in  the  line  of  the  deformity.  In  very  young  patients  this  method 
gives  more  or  less  satisfactory  results,  but  in  cases  of  long  standing 
and  in  older  patients  it  may  require  very  long  periods  of  treatment. 
A  plaster  jacket  with  a  part  to  fit  over  the  pelvis  and  a  part  over  the 
thigh,  joined  together  by  a  hinge  and  reinforced  by  means  of  a  brace, 
may  also  be  used  and  is  said  to  give  excellent  results,  but  requires 
considerable  technical  knowledge  to  properly  apply  and  requires 
very  careful  watching. 

Soutter^  has  described  an  operation  which  has  given  very  satis- 
factory results,  and  is  far  superior  to  the  former  myotomies,  tenot- 
omies and  fasciotomies,  which  were  very  severe  and  not  altogether 
satisfactory.  The  Soutter  operation  consists  of  cutting  down 
longitudinally  between  the  anterior  superior  spine  of  the  ilium  and 
trochanter.  This  is  followed  by  a  division  of  the  tensor  fasciae 
femoris  from  the  trochanter  to  the  anterior  superior  spine  and  then 
separating  the  cartilaginous  part  of  the  spine  and  periosteum  as 
far  down  as  the  anterior  inferior  spine.  The  patient  is  put  up  in 
plaster  in  a  hyperextended  position  and  kept  at  rest  for  six  weeks. 
This  operation  permits  a  new  attachment  of  the  muscles  and  is  the 
most  satisfactory  treatment  yet  devised. 

Abdominal  Muscles. — Paralysis  of  the  abdominal  muscles,  if 
severe,  will  cause  a  flexion  of  the  lower  part  of  the  spine,  so  that  the 
child  walks  with  the  abdomen  protruded.  These  cases  should  be 
supplied  with  a  properly  fitting  cloth  or  leather  corset  to  obtain  the 
necessary  support.  If  the  condition  is  of  long  standing  it  may  be 
necessary  to  use  plaster  jackets  in  attempts  to  reduce  it  first. 

Tendon  Transplantation. — Since  Nicoladani  first  used  this  method 
in  1880  in  poliomyelitis^  it  has  been  a  popular  operation  among 
orthopedic  surgeons  having  to  do  with  paralyzed  children.  The 
operation  is  one  which  is  only  to  be  undertaken  after  very  careful 
study  of  the  particular  case  in  which  it  is  to  be  used,  for  if  this  is 
not  done  the  results  will  be  far  from  satisfactory,  particularly  in  the 
long  run.  It  is  particularly  important  to  have  a  healthy  muscle, 
capable  of  doing  work  that  is  to  be  expected  of  it,  and,  as  a  general 
rule,  flexor  muscles  should  be  used  for  flexion  and  extensors  for 
extension.  While  a  certain  amount  of  hypertrophy  will  take  place 
in  the  muscle,  enabling  it  to  do  increased  work,  this  should  not  be 
too  much  relied  on.    The  first  operations  were  done  by  transplanting 

1  Boston  Med.  and  Surg.  Jour.,  March  12,  1914,  clxx. 

2  Wiener  med.  Presse,   1881,  p.  46. 


TENDON  TRANSPLANTATION  199 

the  active  tendon  in  the  old  tendon  sheath  and  making  the  insertion 
into  the  tendon  below.  Neither  one  of  these  is  very  satisfactory, 
and  in  place  of  using  old  tendons  the  active  tendon  is  transplanted 
in  such  a  manner  that  the  tendon  will  run  in  the  exact  line  in  which 
it  is  expected  to  work,  and  most  operators  now  prefer  to  follow 
the  method  suggested  by  Lange,  of  inserting  the  tendon  directly  into 
the  periosteum.  When  the  tendons  are  not  sufficiently  long  they 
may  be  lengthened  by  the  use  of  silk,  which  eventually  becomes 
covered  with  connective  tissue  and  are  converted  into  tendons. 
In  some  cases  the  tendon  is  passed  through  holes  drilled  into  the 
bone  at  the  site  of  insertion,  which  enables  one  to  get  a  more  certain 
and  definite  attachment.  It  should  be  borne  in  mind  that  before 
tendon  transplantation  is  attempted,  existing  deformities  should  be 
removed  to  their  fullest  extent,  otherwise  the  change  and  deformity 
may  render  the  transplantation  useless.  The  tendons  may  be  passed 
subcutaneously  and  are  usually  drawn  tight  and  the  limb  put  up  in 
an  overcorrected  position.  Plaster  is  used  for  from  five  to  six  months 
or  longer  and  a  brace  for  at  least  a  year  more.  After  the  cast  is 
discarded  the  limb  may  be  treated  by  massage  and  muscle  training, 
but  great  care  should  be  taken  to  wait  until  the  transplanted  tendon 
has  become  thoroughly  settled  in  its  new  position  before  very  much 
work  is  given  to  it. 

Tendon  transplantation  often  gives  most  excellent  results  in  the 
hands  of  skilful  operators,  but  in  many  instances  the  correction  is 
under  what  would  be  desired,  and  occasionally  in  an  effort  to  avoid 
this  the  limit  is  overstepped  and  an  overcorrection  occurs.  The 
most  frequent  and  satisfactory  deformity  treated  by  this  operation 
is  the  talipes  equinus,  in  which  the  extensor  of  the  great  toe  is 
inserted  into  the  anterior  part  of  the  scaphoid.  In  talipes  varus  the 
peroneals  are  affected  and  the  anterior  tibial  is  transferred  to  the 
periosteum  about  the  level  of  the  mediotarsal  joint,  a  little  to  the 
outside  of  the  dorsum  of  the  foot.  In  conjunction  with  the  above 
operation,  or  separately,  the  outer  half  of  the  longitudinally  split 
tendo-Achilles  may  be  passed  through  and  sutured  to  the  peronei 
behind  the  external  malleous.  In  talipes  valgus,  where  the  tibialis 
posticus  is  paralyzed,  generally  the  peroneus  longus  is  passed  by  a 
subcutaneous  route  behind  the  tibia  of  the  inner  side  of  the  foot. 
Another  method  is  to  transplant  the  extensor  longus  hallucis  or  the 
peroneus  tertius  or  both  into  the  internal  cuneiform  bone  at  the 
insertion  of  the  tibialis  anticus.  If  both  of  these  muscles  are  weak 
and  the  tendo-Achilles  is  strong,  the  tendo-Achilles  may  be  split 


200  ■  OPERATIVE   TREATMENT 

longitudinally  and  the  inner  half  transplanted  into  the  tuberosity 
of  the  scaphoid  bone  at  the  insertion  of  the  tibialis  posticus.  If 
necessary,  a  silk  ligament  may  be  used  to  lengthen  it.  This  operation 
does  not  give  very  satisfactory  results  in  talipes  calcaneus. 

The  best  operation  for  calcaneus  deformities,  either  simple  or 
with  valgus  or  varus,  is  Whitman's  astragalectomy,  described  below. 
In  quadriceps  extensor  paralysis  the  hamstrings  may  be  trans- 
planted, provided  the  gastrocnemius  is  in  good  order,  one  or  two 
of  the  tendons  being  extended  with  silk  threads  through  an  inser- 
tion in  the  tubercle  of  the  tibia.  Operations  upon  the  arm  by  this 
method  do  not  give  as  good  results  as  those  on  the  leg.  Sometimes 
part  of  the  pectoralis  major,  or  better,  the  trapezius,  is  used  in  place 
of  the  paralyzed  deltoid. 

Silk  Ligaments. — This  method,  suggested  by  Herz^  and  elaborated 
by  Lange^  consists  of  using  silk  threads  which,  after  being  imbedded 
in  the  tissues  a  certain  length  of  time,  become  covered  with  connec- 
tive tissue  and  so  form  ligaments.  It  is  chiefly  used  in  preventing 
foot-drop. 

Insertions  into  the  periosteum  were  formerly  used,  but  the  results 
are  not  as  good  as  when  the  silk  is  passed  through  holes  drilled  in 
the  bones.  The  silk  may  break  or  the  knots  may  come  through  the 
skin.  The  foot  should  be  immobilized  a  long  time.  Several  weeks  in 
bed  and  a  couple  months  ofi^  the  feet.  In  careful  patients  the  plaster 
may  be  replaced  by  a  brace  in  six  months,  others  should  keep  the 
cast  on  for  at  least  a  year. 

Tenodesis  or  Tendon  Fixation. — Gallic^  has  described  this  operation 
and  its  results  in  detail.  It  consists  of  converting  the  tendons  passing 
over  the  ankle  into  ligaments  by  exposing  them  and  then  burying 
them  in  a  groove  in  the  bone  after  tightening  sufficiently  to  overcome 
deformity.  This  is  scarified  and  sewed  in  position  and  the  foot 
immobilized  in  plaster  for  six  weeks.  Good  results  are  obtained 
in  carefully  planned  operations,  but  it  permanently  disables  the 
muscles  the  tendons  of  which  are  used. 

Tendon  Shortening. — This  method  of  overcoming  deformities  has 
been  tried  by  many  different  operators  using  various  methods. 
Unfortunately,  the  muscle  and  tendon  that  has  been  stretched 
once  will  do  so  again  unless  the  original  cause  of  the  stretching  is 
removed,  hence  relapse  almost  invariably  has  followed. 

1  Miinchen.  med.  Wchnschr.,  1906,  p.  .51. 

2  Ibid.,  1907,  p.  17. 

3  Ann.  Burg.,  March,  1913,  and  October,  1915;  Jour.  Orthop.  Surg.,  .January,  1916. 


ARTHRODESIS  201 

Astragalectomy. — This  operation  was  suggested  by  Whitman.^ 
This  is  used  chiefly  in  very  bad  cases  in  order  to  increase  the  sta})il- 
ity  of  the  foot,  and  it  has  the  advantage  over  arthrodesis  in  that  it 
permits  of  a  sHght  degree  of  motion.  Cases  of  paralysis  of  the 
gastrocnemius  with  resulting  calcaneous  deformities  are  particularly 
suitable  for  this  operation,  which  consists  of  removing  the  astragalus 
and  displacing  the  foot  backward  on  the  tibia,  so  that  the  malleoli 
grasp  the  front  of  the  os  calcis  in  place  of  the  astragalus.  The 
peronei  muscles,  if  active,  are  transplanted  into  the  os  calcis  at  the 
insertion  of  the  tendo- Achilles.  The  external  ligaments  are  sutured 
and  the  leg  placed  up  in  plaster  casts  in  the  position  of  equi  no  valgus 
and  three  or  more  months  allowed  to  elapse  before  any  weight  is 
borne  upon  it,  or  even  longer  time  in  case  there  is  any  doubt  about 
the  condition  of  the  joint.  A  short  plaster  cast  with  cork  under  the 
heel  or  a  brace  that  will  hold  the  foot  in  the  position  of  equinus  is 
to  be  used  when  weight-bearing  is  begun.  Later  an  extension  shoe, 
with  cork  under  the  heel,  will  suffice  to  support  the  foot  in  the  proper 
position.  In  many  instances  the  results  are  very  satisfactory,  but 
in  badly  deformed  feet  there  may  be  occasional  cases  in  which  the 
operation  is  not  a  success. 

Arthrodesis. — This  is  an  operation  in  which  the  end-result  is  a 
stiff  joint  or  an  artificial  ankylosis.  The  operation  is  usually  done 
on  the  ankle,  knee,  hip,  shoulder,  or  elbow,  and  consists  in  removing 
the  cartilaginous  ends  of  the  joint  and  bringing  the  two  surfaces  of 
exposed  bone  together.  This,  under  favorable  conditions,  does  away 
with  the  joint,  and  while  it  results  in  some  lameness  and  stift'ness 
some  patients  prefer  this  to  the  wearing  of  a  brace.  Each  case 
should  be  very  carefully  studied  before  the  operation  is  suggested 
or  performed,  and  it  is  not  a  procedure  to  be  undertaken  except  after 
mature  deliberation,  and  it  should  be  particularly  remembered  that 
it  is  not  an  operation  to  be  used  in  young  children.  In  the  young 
the  greater  amount  of  cartilage  interferes  with  their  getting  a  stift' 
joint,  and  so  much  more  may  have  to  be  removed  it  may  interfere 
with  the  growth  of  the  bone  and  extreme  deformities  may  be  pro- 
duced which  render  the  patient  much  worse  oft'  then  he  was  before. 
After  the  bones  have  attained  their  full  growth  or  near  it  the  opera- 
tion may  ofter  a  certain  amount  of  relief  in  carefully  selected  cases. 
Many  different  operations  have  been  suggested,  particularly  to 
replace  arthrodesis  of  the  ankle-joint.  An  account  of  these  will  be 
found  in  Lovett's  Treatment  of  Infantile  Paralysis,  p.  109. 

1  Am.  Jour.  Med.  Sc,  November,  1902;  Ann.  Surg.,  February,  190S. 


202  OPERATIVE  TREATMENT 

Other  Operations. — In  certain  selected  cases  other  operative 
procedures  are  sometimes  carried  out.  Knock-knees  that  resist 
ordinary  treatment  may  be  cured  by  an  osteotomy,  and  this  may  be 
used  sometimes  in  correcting  other  deformities.  Resections  of  the 
joints  is  sometimes  done,  particularly  in  some  of  the  more  extreme 
deformities  of  very  long  standing. 

Nerve  Transplantation. — This  operation  has  received  considerable 
study,  but  the  results  have  probably  not  been  anything  like  what 
would  have  been  hoped  from  the  operation.  If  the  transplantations 
are  made  early,  part  of  the  result  at  least  might  have  been  obtained 
without  transplantation,  and  if  the  operation  is  done  late  the  changes 
in  the  nerves  militates  against  the  success  of  it.  The  largest  number 
of  operations  have  apparently  been  done  by  Spitzy  and  Stoeffel.^ 
They  report  61  operations,  and  in  30  per  cent,  the  results  were  good, 
in  40  per  cent,  the  results  regarded  as  not  entirely  satisfactory,  and 
in  the  remaining  30  per  cent,  the  results  were  bad. 

The  most  frequent  operation  is  to  use  the  obturator  to  the  anterior 
crural  in  the  hip  or  the  peroneal  nerve  to  the  tibial,  or  vice  versa} 
These  operations  do  not  give  sufficiently  good  results  to  warrant 
their  use  in  ordinary  work. 

The  Neurotization  of  Muscles. — Erlacher^  and  Steindler^  found 
from  observations  on  animals  that  it  is  possible  to  transfer  a  nerve 
directly  into  the  muscle,  and  that  eventually  the  nerve  will  form 
endings  in  the  muscle  with  a  certain  amount  of  power.  This  opera- 
tion, after  it  is  developed  more  fully,  may  be  of  some  service  in 
poliomyelitis  in  the  future. 

Summary. — ^Lovett^  has  given  the  following  useful  summary  which 
shows  his  own  preference  for  operation  in  the  various  deformities. 
It  should  be  remembered,  however,  that  there  are  many  differences 
of  opinion  even  among  the  most  experienced  operators,  but  this 
summary  represents  what  one  very  successful  orthopedic  surgeon 
has  found  to  be  of  value  in  his  own  experience. 

Talipes  Equinus. — Stretching;  tenotomy  of  the  tendo-Achilles 
if  the  anterior  muscles  have  fair  power;  transplantation  of  the 
extensor  of  the  great  toe  or  other  extensors  into  the  tarsal  bones; 
anterior  silk  ligaments  with  or  without  tenotomy;  tenodesis; 
arthrodesis. 

1  Lange  and  Spitzy:  Handbuch  der  Kinderheilk.,  Leipzig,   1910. 

2  See  also  Osgood,  Boston  Med.  Surg.  Jour.,  June  30,  1910,  and  Zeiss,  ibid.,  May 
11,  1911. 

3  Am.  Jour.   Orthop.   Surg.,   1915,   xiii,   22.  ^  Ibid.,  p.  33 
6  Treatment  of  Infantile  Paralysis,  p.  121. 


SUMMARY  203 

Talipes  Calcaneus. — Astragalectomy ;  tenodesis;  arthrodesis. 

Talipes  Varus. — Transplantation  of  tlie  anterior  tibial  when  that 
is  active  to  the  outer  third  of  the  foot;  silk  ligament  from  the  fibula 
to  the  cuboid;  astragalectomy;  tenodesis;  arthrodesis. 

Talipes  Valgus. — Transplantation  of  one  of  the  ])eroneals  to  the 
inner  side  of  the  foot;  silk  ligaments  from  the  tibia  to  the  inner 
side  of  the  tarsus;  astragalectomy;  tenodesis  or  arthrodesis. 

Flexed  Knee. — Stretching  or  open  division  of  the  hamstrings. 

Ilypere.rtended  Knee. — In  cases  in  which  the  quadriceps  is  par- 
alyzed and  the  hamstrings  and  gastrocnemius  are  good,  transplanta- 
tion of  one  or  two  hamstrings  into  the  tubercle  of  the  tibia. 

Knock-knee. — Supracondyloid  osteotomy   (Soutter's  operation). 

Flexed  Hip. — Fasciotomy  if  severe. 

Dislocated  Hip. — Arthrodesis. 

Shoulder. — Dropping  of  the  arm  away  from  the  glenoid  cavity; 
arthrodesis  of  the  joint;  silk  ligaments. 

In  cases  of  deltoid  paralysis  with  the  pectoralis  major  active  the 
origin  of  the  latter  may  be  transplanted  into  the  spine  of  the  scapula. 

Operation  in  the  forearm,  elbow^,  and  ^^Tist  cannot  be  summarized, 
as  they  vary  greatly  in  individual  cases.  Arthrodesis  of  the  elbow 
is  useful,  but  the  operation  is  not  applicable  at  the  wrist  on  account 
of  the  nature  of  the  joint. 


CHAPTER   XV. 

EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING. 

It  is  very  important  in  treating  paralyzed  cases  to  determine,  as 
exactly  as  possible,  what  muscle  or  group  of  muscles  is  affected,  and, 
having  done  this,  to  prescribe  suitable  exercises  that  will  tend  to 
strengthen  the  weakened  muscles,  and,  as  far  as  possible,  train  the 
nervous  impulses  to  come  from  the  brain  through  the  spinal  cord 
along  new  paths.  It  is  advisable  to  make  a  record  of  the  loss  of 
power,  not  only  the  location,  but  the  extent  of  it.  The  location  is 
best  charted  on  a  figure  of  the  body  showing  the  various  muscles, 
and  the  extent  of  it  may  be  noted  as  complete  or  partial,  or,  better 
still,  if  the  patient  is  in  an  institution  equipped  for  it  the  extent 
may  be  noted  by  using  Lovett  and  Martin's  spring-balance  test. 
It  is  very  essential  that  the  exercises  be  given  to  the  mother  or 
nurse,  or  whoever  is  to  supervise  the  training,  in  a  very  exact  way, 
and  in  most  cases  the  movement  used  to  determine  the  presence  or 
absence  of  loss  of  power  is  the  exercise  used  in  the  treatment.  Fol- 
lowing the  excellent  set  of  exercises  and  tests  formulated  by  Miss 
Wright  and  published  in  Lovett's  book,  we  have  worked  out  a  set 
of  tests  and  exercises,  and  have  also  noted  the  muscles  and  nerves 
involved  and  added  illustrations  to  make  the  movements  more 
clear.  The  patient  should  be  taught  to  concentrate  his  mind  on 
the  movement  that  he  is  trying  to  make.  The  importance  of  this 
is  noted  by  Barlow.  The  exercises  should  always  be  done  under 
supervision  and  at  word  of  command.  The  child  or  any  other  indi- 
vidual can  scarcely  carry  out  satisfactory  exercises  alone  no  matter 
how  intelligent  or  well  meaning.  The  patient  should  be  told  to 
make  a  certain  exercise  and  then  make  it.  If  the  attention  flags, 
the  exercise  should  be  stopped  for  a  few  moments'  rest  and  then 
should  be  started  over  again.  Accuracy  and  precision  of  movement 
are  especially  to  be  aimed  at,  and  while  the  tedium  of  doing  the 
same  thing  over  and  over  may  be  relieved,  if  possible,  by  making 
some  sort  of  a  game  of  the  exercises,  the  importance  of  having  the 
thing  ordered  done  exactly  must  never  be  lost  sight  of.  The 
exercises  should  be  carried  on  with  the  operator  and  the  patient  in 


EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING     205 

a  room  alone,  as  outsiders  detract  the  attention,  and  with  some 
chikh'en  it  is  difficult  to  get  them  to  do  things  in  the  presence  of  a 
third  person.  It  is  important  to  remember  that  the  patient  should 
make  a  continuous  movement  when  once  he  is  started,  and  if  the 
muscle  is  not  strong  enough  for  this  the  end  of  the  movement  should 
be  aided  by  the  operator,  and  this  should  be  done  in  such  a  way  as 
to  have  the  movement  actually  continuous  and  not  merely  pick 
up  after  the  patient  has  stopped.  The  exercises  and  movements 
that  the  patient  can  make  most  easily  should  be  used  first,  and,  as 
power  returns,  others  may  be  added.  As  soon  as  the  patient  can 
make  the  movement  completely  without  assistance,  resistance  may 
be  gradually  added  by  the  operator ;  but  this  should  always  be  very 
slight  at  first  and  increased  at  a  rate  that  is  not  too  trying  for  the 
patient.  Resistance  should  be  greatest  at  the  middle  of  the  move- 
ment and  weak  both  at  the  start  and  at  the  end.  Exercises  should 
be  carried  on  six  days  in  the  week,  and  the  seventh  day  may  be 
taken  for  rest,  which  will  prevent  them  from  going  stale.  The 
exercises  should  be  carried  on  rather  slowly  and  sufficient  time 
allowed  between  each  movement  to  permit  of  complete  recovery. 
Each  exercise  may  be  gone  through  with  from  one  to  ten  times. 
If  the  patient  does  not  do  any  movement  as  well  as  the  preceding 
one  he  should  be  allowed  a  few  moments'  rest  before  going  on. 
In  every  case  it  is  of  the  utmost  importance  to  avoid  fatigue  either 
of  the  muscles  or  of  the  attention.  It  should  be  remembered  that 
young  children  and  even  older  ones  have  their  attention  tired  out 
very  quickly,  and  if  the  child's  interest  begins  to  flag  it  is  better 
to  stop  the  exercise,  divert  it  for  a  few  moments,  and  then  try  again. 
The  patient  is  best  exercised  on  a  flat,  hard  table  rather  than  on  a 
mattress  or  bed,  which  gives  under  the  movements,  and  the  best 
results  are  obtained  when  the  patient  is  entirely  undressed,  which 
can  always  be  done  in  the  case  of  young  children. 

Group  of  Muscles  which  Flex  the  Head  on  the  Neck. 

Muscles.  Nerves. 

Sternomastoid  (chief).  Spinal  accessory. 

Omohyoid.  Descendens  and  communicans. 

Sternohyoid.  Descendens  and  communicans. 

Sternothyroid.  Descendens  and  communicans. 

Mylohyoid.  Branch  of  inferior  dental. 

Rectus  capitis  anticus.  First  and  second  cervical. 

Longus  colli.  Lower  cervical. 

Digastric.  Mylohyoid  branch  of  inferior  dental 

and  facial. 


206      EXAMINATION  OF  MUSCLES  AND  MUSCLE   TRAINING 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
flexes  the  head  on  the  neck — that  is,  brings  the  head  forward. 

Test. — 1.  In  this  test  the  patient  may  lie  on  the  table  flat  on 
his  back  and  attempt  to  raise  the  head  from  the  table  without 
raising  the  shoulders. 


Fig.  67. — Illustrating  attempt  to  flex  head  with  shoulders  held  down. 

2.  In  this  second  test  the  patient  sits  down  and  allows  the  head 
to  hang  over  backward  and  then  tries  to  raise  it  forward  in  an 
attempt  at  flexion. 


Fig.  68. — Second  step.    Flexion  completed,  shoulders  still  held  down. 


Exercises. — 1.  The  patient  in  this  exercise  is  placed  flat  on  his 
back  and  attempts  flexion  of  the  head  by  bending  it  forward.  Care 
must  be  taken  that  the  shoulders  are  not  raised  from  the  table. 

2.  The  patient  is  seated  in  this  exercise  and  attempts  to  bring 
the  head  forward  from  a  backward  or  extended  position. 


TEST 


207 


Group  of  Muscles  which  Extend  the  Head  on  the  Neck. 


Muscles. 
Trapezius. 
Splenius  capitis. 
Rectus  capitis  posticus. 
Obliquus  capitis  inferior. 
Semispinalis  capitis. 


Nerves. 
Spinal  accessory  and  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
extends  the  head  on  the  neck — that  is,  bends  the  head  backward. 

Test. — The  patient  lies  on  the  table  face  downward  and  attempts 
to  raise  the  head. 

Exercise. — The  patient  assumes  the  same  position  as  in  the  test, 
and  the  exercise  consists  in  the  attempt  to  raise  the  head  from  the 
table,  without  moving  the  shoulders.  This  may  be  done  with  and 
without  resistance. 

Group  of  Muscles  which  Flex  the  Head  Laterally. 

Muscles.  Nerves. 


Sternomastoid. 
Splenius  capitis. 
Longissimus  capitis. 
Obliquus  capitis  superior. 
Rectus  capitis  lateralis. 
Semispinalis  capitis. 


Spinal  accessory  and  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 
Posterior  branch  of  cervical  plexus. 


Muscle  Action. — This  group  of  muscles  flexes  the  head  laterally 
that  is,  bend  it  to  one  side  or  the  other. 


Fig.  69. — Patient  lying  on  unaffected  side  attempts  to  raise  head 
laterally  to  side  affected. 

Test. — The  patient  in  this  test  lies  on  the  side,  which  is  unaf- 
fected, and  attempts  to  raise  the  head  laterally  from  the  table  or  bed. 


208      EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

Exercise. — The  patient  in  this  exercise  assumes  the  same  posi- 
tion as  in  the  test  and  tries  to  flex  the  head  of  the  suspected  side 
without  moving  the  body  from  the  table.  This  may  be  done  with 
and  without  resistance. 

Group  of  Muscles  which  Rotate  the  Head. 


Muscles, 

Sternomastoid. 

Splenius  capitis. 

Longissimus  capitis. 

Semispinalis  capitis. 

Obliquus  capitis  inferior. 

Rectus  capitis  posterior  major  and  minor. 


Nerves. 

Spinal  accessory  and  cervical  plexus. 

Cervical  plexus. 

Cervical  plexus. 

Cervical  plexus. 

Cervical  plexus. 

Cervical  plexus. 


Muscle  Action. — This  group  of  muscles  under  normal  conditions 
rotates  the  head  to  one  side  or  the  other.    A  turning  movement. 

Test. — In  this  test  the  patient  is  seated  and  turns  the  head  from 
one  side  to  the  other. 


Fig.  70. — Patient  seated  attempts  rotation  of  head  against 
resistance  of  examiner's  hand. 


Exercise.— -In  this  exercise  the  patient  is  seated  with  the  head 
turned  toward  the  unaffected  side  and  then  attempts  to  rotate  it 
toward  the  side  on  which  the  paralysis  has  taken  place.  This  may 
be  done  with  or  without  resistance. 


EXERCISES  209 

Group  of  Muscles  which  Elevate  the  Shoulders. 

Muscles.  Nerves. 

Trapezius.  Cervical  plexus. 

Levator  anguli  scapulae.  Cervical  plexus  and  posterior  scapular. 

Rhomboids.  Posterior  scapular. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
elevate  the  shoulders,  that  is,  shrugs  them. 

Test. — The  patient  is  seated  and  shrugs  the  shoulders. 
Exercise. — Same. 

Group  of  Muscles  which  Flex  the  Humerus. 

Muscles.  Nerves. 

Deltoid  (anterior  fibers).  Circumflex. 

Pectoralis  major.  Anterior  thoracic. 

Coracobrachialis  (above  the  horizontal         Musculocutaneous. 

line) . 
Serratus  magnus.  Posterior  thoracic. 

Trapezius.  Cervical  plexus. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
brings  the  humerus  forward  and  flexes  it  in  the  horizontal  line. 
This  action  is  caused  by  the  first  group  of  muscles  until  the  humerus 
approaches  the  horizontal  line,  when  the  serratus  magnus  and  trape- 
zius begin  to  act,  thereby  fixing  the  scapula. 

Test. — 1.  The  patient  lies  face  downward  on  the  table  or  bed 
with  the  arm  extended  over  the  head  and  attempts  to  raise  the  arm 
without  raising  the  body. 

2.  If  the  patient  can  stand  or  is  able  to  be  seated  he  attempts 
to  raise  the  hiunerus  to  the  horizontal  line  anteriorly.  This  test 
tries  out  all  the  muscles. 

3.  The  patient  is  seated  in  this  test  and  attempts  to  flex  the 
humerus  as  in  the  preceding  test.  The  examiner,  in  order  to  throw 
the  action  of  the  serratus  magnus  and  trapezius  out,  presses  firmly 
between  the  point  of  the  shoulder  and  the  neck  of  the  patient. 

Exercises. — 1.  With  the  patient  lying  on  his  face  and  the  arms 
extended  over  the  head,  attempts  are  made  to  have  the  patient  raise 
the  arm  from  the  bed  without  raising  the  body. 

2.  The  patient  m  the  seated  or  standing  position  attempts  to 
raise  the  arm  in  horizontal  flexion  with  and  without  resistance  on 
the  part  of  the  examiner. 
14 


210    EXAMINATION  OF  MUSCLES  AND   MUSCLE  TRAINING 

3.  The  patient  is  seated  and  attempts  to  raise  the  humerus 
forward  in  flexion,  while  the  examiner  makes  pressure  as  in  the 
test  described  above. 


Fig.  71. — Attempt  to  flex  humerus  forward  and  upward  against  resistance. 


Group  of  Muscles  which  Extend  the  Humerus. 

Muscles.  Neeves. 


Pectoralis  majoi  (sternal  fibers). 

Latissimus  dor  si. 

Teres  major. 

Teres  minor. 

Infraspinatus. 

Triceps. 

Hyperextension. 
Latissimus  dorsi. 
Teres  major. 
Teres  minor. 
Infraspinatus. 
Deltoid  (posterior  fibers). 


Anterior  thoracic. 
Long  subscapular. 
Lower  subscapular. 
Circumflex. 
Suprascapular. 
Musculospiral. 


Long  subscapular. 
Lower  subscapular. 
Circumflex. 
Suprascapular. 
Circumflex. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
extends  the  humerus — that  is,  brings  the  arm  downward  and  for- 
ward— and  the  lower  group  (designated  above)  hyperextends  the 
humerus,  which  means  to  carry  the  arm  backward  or  back  of  the 
body.  The  scapula  is  fixed  in  this  action  by  the  pectoralis  minor, 
trapezius,  and  rhomboids. 


TESTS 


211 


Tests. — 1.  Tlie  patient,  either  standing  or  sitting,  with  the 'arm 
raised  abo^'e  the  head  brings  it  down  forward.  This  action  is  car- 
ried on  until  the  arm  comes  in  hne  with  the  body. 


Fig.  72. — Patient  seated,  attempts  to  extend  humerus  by  raising  arm  backward. 


Fig.  73. — With  patient  l^ing  on  face  attempt  to  hyperextend  humerus, 
resistance  being  offered. 


2.  The  patient,  either  standing  or  sitting,  with  the  arm  at  the 
side  carries  it  backward  as  far  as  he  is  able. 

3.  The  patient  lies  face  downward  on  the  table  or  bed  and 
attempts  to  raise  the  arm  backward. 


212     EXAMINATION  OF   MUSCLES  AND  MUSCLE  TRAINING 

Exercises. — 1.  If  the  patient  is  able  to  stand  or  be  seated  he 
attempts  to  bring  the  arm  downward  and  forward  from  a  position 
above  his  head. 

2.  The  patient  seated  attempts  to  bring  the  arm  backward 
from  a  position  at  the  side.  This  may  be  done  with  and  without 
resistance. 

3.  The  patient  lies  face  downward  and  attempts  to  hyperextend 
the  arm  by  raising  it  backward.  This  may  also  be  done  with  and 
without  resistance. 

Group  of  Muscles  which  Abduct  the  Humerus. 

Muscles.  Nerves. 

Deltoid  (middle  fibers).  Circumflex. 

Supraspinatus.  Suprascapular. 

Biceps.  Musculocutaneous. 

Above  the  Horizontal  Line. 
Serratus  magnus.  Posterior  thoracic. 

Trapezius  (acromial  and  inferior  fibers) .  Cervical  plexus. 


Fig.  74.- 


-Attempt  to  raise  humerus  laterally  (abduction)  with  shoulder  girdle 
held  firmly  and  resistance  against  humerus. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
abducts  the  humerus — that  is,  raises  the  humerus  to  the  side.  The 
first  group  raises  the  arm  above  the  horizontal  line.  The  serratus 
and  trapezius  fix  the  scapula  in  this  as  they  do  in  the  other  action 
of  the  shoulder  girdle  and  the  muscular  groups. 


EXERCISES  213 

Test. — 1.  The  patient,  either  standing  or  sitting,  attempts  to 
raise  the  arm  sideways  to  the  horizontal  hne.  In  this  test  it  is  best 
to  keep  the  palm  downward,  as  the  biceps  is  kept  out  of  action  in 
this  way. 

2.  The  patient  assumes  a  position  flat  on  the  table  or  bed,  either 
on  his  back  or  face,  and  attempts  to  raise  the  hmnerus  from  the 
side  to  shoulder  height.  The  palm  should  be  kept  downward  and 
the  shoulder  fixed  by  the  hand  of  the  examiner,  as  explained  before. 
Should  the  patient  be  lying  on  his  back  the  anterior  fibers  of  the 
deltoid  are  brought  into  play,  if  on  his  face,  the  posterior  fibers. 
It  is  possible  for  the  anterior  fibers  to  be  paralyzed,  and  vice  versa. 

Exercises. — 1.  The  patient,  standing  or  sitting,  with  the  arm  at 
the  side  attempts  to  raise  it  from  the  side  until  it  is  above  his  head. 
The  palm  must  be  downward  and  the  shoulder  girdle  fixed  as  in 
the  test.    This  exercise  may  be  tried  with  and  without  resistance. 

2.  The  patient  assumes  the  attitude  of  either  l^ing  on  his  back 
or  face.  The  attempt  is  then  made  to  raise  the  arm  laterally  from 
the  side.  In  this  exercise  the  examiner  may  offer  resistance  against 
the  arm  when  the  patient  attempts  to  abduct  it. 

Group  of  Muscles  which  Abduct  the  Humerus  Horizontally. 

Muscles.  Nehves. 

Deltoid  (middle  fibers) .  Circumflex. 

Deltoid  (posterior  fibers).  Circumflex. 

Latissimus  dorsi.  Long  subscapvilar. 

Teres  major.  Lower  subscapular. 

Teres  minor.  Circumflex. 

Infraspinatus.  Suprascapular. 

Subscapularis.  Short  subscapular. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
abduct  the  humerus  horizontally — that  is,  carries  the  arm  back  at 
shoulder  level. 

Test. — 1.  The  patient  lies  face  do^^^lward  on  the  table  and 
attempts  to  raise  the  arms  from  the  table.  The  position  of  the 
arms  before  the  test  is  at  right  angle  to  the  body  and  stretched  out 
sideways. 

2.  The  patient  is  seated  facing  the  table  with  his  arm  in  a  posi- 
tion of  adduction,  by  having  it  crossed  over  to  the  shoulder  of  the 
opposite  side.    In  this  position  he  attempts  to  abduct  it. 

Exercises. — 1.  The  patient  lies  face  do^siiward  as  in  the  test, 
with  his  arms  at  right  angles  to  the  bodv  and  stretched  out  later- 


214     EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

ally.    He  attempts  as  in  the  test  to  raise  the  arms  from  the  table. 
This  may  be  done  with  and  without  resistance. 

2.  The  patient  is  seated  with  his  arm  in  a  position  of  extreme 
adduction  by  having  it  crossed  over  to  the  shoulder  of  the  opposite 
side.  In  this  exercise  he  attempts  to  abduct  against  the  resistance 
of  the  examiner  and  without  it. 

Group  of  Muscles  which  Adduct  the  Humerus. 

Muscles.        _  Nerves. 

Pectoralis  major.  Anterior  thoracic. 

Latissimus  dorsi.  Long  subscapular. 

Teres  major.  Lower  subscapular. 

Teres  minor.  Circumflex. 

Infraspinatus.  Suprascapular. 

Subscapularis.  Short  subscapular. 

Deltoid  (posterior  fibers) .  Circumflex. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
brings  the  humerus  to  the  side,  that  is,  adducts  it. 

Test. — 1.  The  patient,  either  standing  or  seated,  brings  the  arm 
down  to  the  side. 

2.  The  patient  lies  on  the  table  or  bed,  first  on  his  back  and  then 
on  his  face.  In  either  of  these  positions  he  tries  to  bring  the  humerus 
to  the  side  of  the  body.  If  he  lies  on  his  back,  the  pectoralis  major 
shows  to  better  advantage;  if  on  his  face,  the  latissimus  dorsi. 

Exercises. — 1.  The  patient,  either  seated  or  standing,  attempts 
to  bring  the  humerus  to  the  side  against  the  resistance  of  the 
examiner. 

2.  The  patient,  lying  on  the  back  or  face  downward,  attempts 
to  bring  the  arm  to  the  side  against  the  resistance  of  the  examiner 
or  without  it. 

Group  of  Muscles  which  Adduct  the  Humerus  Horizontally. 

Muscles.  Nerves. 

Coracobrachialis.  Musculocutaneous. 

Pectoralis  major.  Anterior  thoracic. 

Deltoid  (anterior  fibers) .  Circumflex. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
adducts  the  humerus  horizontally  toward  the  middle  line.  This  is 
done  at  shoulder  level. 


MUSCLE  ACTION 


215 


Tests. — 1.  The  patient  lies  on  his  back,  and  in  this  position,  with 
the  arms  straight  out  at  either  side,  pahns  up,  at  shoulder  level, 
brings  the  arms  forward  to  the  midline  of  the  body  until  the  palms 
meet  above  vertically.    This  test  is  chiefly  for  the  pectoralis  major. 

2.  The  patient  is  seated  against  the  table  with  the  affected  side 
supported  at  shoulder  height  and  attempts  to  slide  the  arm  forward. 

Exercises. — 1.  The  patient  lies  on  his  back  with  his  arms  at 
the  side,  straight  out  and  palms  up.  In  this  position  he  brings  the 
arms  together  by  touching  the  palms  vertically  above  his  head. 
This  may  be  done  with  and  without  resistance. 

2.  The  patient  does  the  exercise  as  described  in  the  second  test, 
that  is,  to  rest  the  affected  side  on  the  table  at  shoulder  level  and 
draw  the  arm  forward.  The  exercise  may  be  tried  with  and  without 
resistance. 


Group  of  Muscles  which  Rotate  the  Hutmerus  Inward. 

Muscles.  Nerves. 


Pectoralis  major. 
Deltoid  (anterior  fibers). 
Teres  major. 
Latissimus  dorsi. 
Subscapularis. 


Anterior  thoracic. 
Circumflex. 
Long  subscapular. 
Long  subscapular. 
Short  subscapular. 


Fig.  75. — Attempt  to  rotate  humerus  inward,  resistance  against  ulnar  side  of  wrist. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
rotates  or  twists  the  himierus  inward. 


216      EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 


Geoup  of  Muscles  which  Rotate  the  Humerus  Outward. 

Muscles.  Nerves. 


Deltoid  (posterior  fibers). 

Infraspinatus. 

Teres  minor. 


Circumflex. 

Suprascapular. 

Circumflex. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
rotates  the  humerus  outward. 

Tests. — (The  tests  and  the  exercises  are  alike  for  inward  and 
outward  rotation,  that  is,  the  positions  are  the  same,  and  the  only 
difference  lies  in  the  twisting,  therefore  they  are  both  given  below 
under  one  heading.) 


Fig.  7C. — Attempt  to  rotate  humerus  outward,  resistance  against  radial  side  of  wrist. 


1.  The  patient  lies  on  his  abdomen  face  downward,  with  the 
arm  stretched  out  sideways  at  shoulder  height.  The  forearm  and 
hand  hang  over  the  table,  so  that  the  former  is  bent  at  right  angles 
to  the  arm.  The  examiner  steadies  the  upper  arm  while  the  patient 
attempts  to  raise  the  hand  backward  and  upward  in  an  attempt  at 
rotation.  When  the  patient  raises  the  hand  forward  and  upward 
he  attempts  outward  rotation. 

2.  The  patient  lies  on  his  back  with  the  arms  close  at  the  side 
and  the  elbows  bent  at  right  angles.  The  forearm  rests  across  the 
chest.  He  then  attempts  to  turn  the  arm  outward  and  inward, 
pivoting  it  on  the  elbow. 


EXERCISES 


217 


Exercises. — 1.  The  patient  assumes  the  position  as  described  in 
the  test  by  lying  face  downward  and  his  arm  stretched  out  side- 
ways. The  forearm  and  hand  hang  over  the  side.  He  attempts  to 
rotate  the  arm  outward  by  bringing  the  hand  forward  and  upward 
with  the  examiner  ofl'ering  resistance  against  the  radial  side  of  the 
wrist.  The  examiner  then  offers  resistance  against  the  ulnar  side 
of  the  wrist,  while  the  patient  attempts  to  raise  the  hand  backward 
and  upward  for  inward  rotation.  The  arm  must  be  held  by  the 
examiner. 

2.  The  patient  lies  on  his  back  with  the  arms  at  the  side  and 
pivoted  on  the  elbows,  which  are  at  right  angles  to  the  arm,  and, 
as  described  in  the  test,  attempts  inward  and  outward  rotation  by 
turning  the  forearm  outward  at  first  and  then  bringing  it  back. 


Group  of  Muscles  which  Flex  the  Forearm. 

Muscles.  Nerves. 


Biceps 

Brachialis 

Supinator  longus 

Pronator  radii  teres 

Flexor  carpi  radialis 

Flexor  carpi  ulnaris 

Palmaris  longus 

Flexor  digitorum  sublimus 

Flexor  digitorum  profundus 

Lumbricales 

Interossei 

Flexor  brevis  minimi  digiti 

Extensor  carpi  radialis. 

Extensor  carpi  ulnaris 

Extensor  communis  digitorum 

Extensor  longus  pollicis 


Musculocutaneous- 

Musculospiral. 

Musculospiral. 

Median. 

Median. 

Ulnar. 

Median. 

Median. 

Anterior  interosseous  and  ulnar. 

Ulnar  and  median. 

Ulnar. 
_  Ulnar. 

Musculospiral. 
Extensors    of    wrist 

and  fingers  in  pro-  }  Posterior  interosseous, 
nation 


Flexors  of 
wrist 


Flexors  of 
fingers 


Note. — Biceps  is  a  flexor  supinator.     Pronator  teres  is  a  flexor  pronator. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
flexes  the  forearm  on  the  upper  arm — that  is,  bends  the  elbow. 

Tests. — 1.  The  patient  is  seated  and  bends  the  elbow  until  the 
hand  touches  the  shoulder;  this  should  be  tried  both  in  pronation 
and  supination  in  order  to  test  out  all  the  muscles. 

2.  The  patient  lies  on  the  affected  side  and  bends  the  elbow  until 
the  hand  touches  the  shoulder. 

Exercises. — 1.  The  patient  is  seated  and  bends  the  elbow  to  the 
shoulder  until  the  hand  touches,  both  in  pronation  and  supination, 
with  and  without  resistance. 


218      EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

2.  The  patient  lies  on  his  back  with  the  upper  arm  supported 
vertically  and  flexes  the  forearm  with  and  without  resistance. 


Fig.  77. — Patient  attempts  to  flex  forearm.     Resistance  offered  by  examiner. 


Group  of  Muscles  which  Extend  the  Forearm. 


MtrscLES. 

Triceps. 

Anconeus. 

Extensor  carpi  radialis 

Extensor  carpi  ulnaris 

Extensor  communis  digitorum 

Extensor  longus  pollicis 

Extensor  indicis  proprius 

Extensor  minimi  digiti 

Lumbricals 

Interossei 


Nerves. 

Musculospiral. 
Musculospiral. 

Extensors  of  wrist      >  Posterior  interosseous. 


Extensors  of  fingers 
in  supination 


Posterior  interosseous. 

Median  and  ulnar. 
Ulnar. 


Muscle  Action.^ — Under  normal  conditions  this  group  of  muscles 
extends  the  forearm — ^that  is,  straightens  the  elbow. 

Tests, — 1 .  The  patient  is  seated  with  the  upper  arm  raised  above 
the  shoulder  and  supported,  with  the  elbow  flexed.  He  then 
attempts  to  extend  the  forearm. 

2.  The  patient  lies  on  the  afi^ected  side  with  the  elbow  flexed  and 
attempts  to  straighten  it. 

Exercises. — 1.  The  patient  lies  on  his  back  with  the  upper  arm 
in  a  vertical  position  and  elbow  flexed  and  then  attempts  to 
straighten  it  with  and  without  resistance. 


MUSCLE  ACTION 


219 


2.  The  patient  is  seated  witli  tlie  forearm  flexed  and  attempts 
to  extend  it.    This  mav  also  be  done  \vith  and  without  resistance. 


Fig.  78. — Patient  seated  with  forearm  in  flexion  attempts  extension.    Resistance 
offered  against  ■wrist  bj'  examiner. 


Group  of  Muscles  t\tiich  Supinate  the  Forearm  .vxd  Hand. 


Muscles. 
Supinator  radii  bre\'is. 
Supinator  radii  longus. 
Biceps. 


Xerves. 
Posterior  interosseous. 
Musculospiral. 
Musculocutaneous. 


Fig.  79. — Forearm  on  lap  with  hand  palm  down.     Position  in  which 
supination  is  attempted. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
supinate  the  forearm  and  hand — that  is.  tiu'n  the  palm  upward. 


220      EXAMINATION  OF^MVSCLES  AND^MUSCLE  TRAINING 

Test. — The  patient  is  seated  with  the  forearm  in  his  lap  and  the 
palm  tm-ned  down  and  then  attempts  to  turn  the  palm  upward. 

Exercise. — The  patient  is  seated  as  in  the  test  and  with  the  palm 
turned  down;  he  attempts  to  supinate  the  forearm  by  turning  the 
palm  upward. 


Group  of  Muscles  which  Pronate  the  Forearm  and  Hand. 


Muscles. 


Pronator  radii  teres. 
Pronator  quadratus. 
Flexor  carpi  radialis. 


Neeves. 

Median. 

Anterior  interosseous. 

Median. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
pronate  the  forearm  and  hand,  that  is,  turn  the  palm  downward. 

Test. — ^The  patient  is  seated  with  the  forearm  resting  in  his  lap 
and  the  palm  turned  up,  and  then  attempts  to  turn  the  palm 
down.    The  examiner  may  grasp  the  hand  and  resist  this  movement. 


Fig.  so. — Forearm  on  lap  with  palm  up.     Position  in  which  pronation 
is  attempted. 


Exercise. — The  patient  is  seated  as  in  the  test  and  attempts  to 
turn  the  palm  downward  with  the  examiner  resisting  by  grasping 
the  hand. 


EXERCISES 


221 


Group  of  Muscles  which  Flex  the  Wrist. 

Muscles.  Nerves. 


Flexor  carpi  radialis. 
Flexor  carpi  ulnariis. 
Palmaris  longus. 
Flexor  sublimis  cligitorum. 
Flexor  profundus  digitoruni. 
Flexor  longus  pollicis. 


Median. 

Ulnar. 

Median. 

Median. 

Anterior  interosseous  and  ulnar. 

Anterior  interosseous  and  ulnar. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
flexes  the  wrist — that  is,  draws  the  hand  downward.  In  case  of 
paralysis,  extension  of  the  wrist  is  present. 

Tests. — 1.  The  patient  places  the  forearm  on  the  table  with  the 
hand  extended  over  the  edge  and  the  palm  upward.  In  this  posi- 
tion he  tries  to  flex  the  wrist. 

2.  The  patient  places  the  arm  on  the  table  with  the  ulnar  side 
down  and  attempts  to  flex  the  wrist. 

Exercises. — 1.  The  patient  is  seated  at  the  table  with  the  forearm 
resting  on  it.  The  hand  is  extended  over  the  edge  of  the  table  and 
the  palm  upward.  He  attempts  to  flex  the  ^wist  with  and  without 
resistance. 


Fig.  8L — Forearm  supported  on  table,  attempt  to  flex  wrist  against  resistance. 


2.  The  patient  is  seated  and  places  the  hand  as  in  the  second 
test,  ulnar  side  down.  He  attempts  to  flex  the  wrist  with  and  with- 
out resistance  of  the  examiner. 


222      EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 


Group  of  Muscles  which  Extend  the  Wrist. 


Muscles. 
Extensor  carpi  radialis. 
Extensor  carpi  ulnaris. 
Extensor  communis  digitorum. 
Extensor  longus  pollicis. 


Neeves. 
Musculospiral. 
Posterior  interosseous. 
Posterior  interosseous. 
Posterior  interosseous. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
extends  the  wrist  on  the  forearm.  In  case  paralysis  should  occur, 
the  condition  of  wrist-drop  is  present  here. 

Test. — The  patient  places  his  forearm  on  the  table  with  the 
hand  over  the  edge  of  the  table  palm  down.  He  then  attempts  to 
extend  the  wrist  in  this  position. 

Exercises. — 1.  The  patient  places  his  forearm  on  the  table  with 
his  palm  down.  The  exercise  consists  in  extending  the  wrist  against 
the  resistance  of  the  examiner's  hand,  or  without  it. 


Fig.  82. — Forearm  suppDrU'd  uii  table.     Attempt  to  extend  wrist  against  resistance. 

2.  The  patient  is  seated  at  the  table  and  places  his  forearm  on 
the  table,  ulnar  side  down.  He  then  attempts  to  extend  the  wrist 
from  a  position  of  flexion,  with  and  without  resistance. 


Group  of  Muscles  which  Abduct  the  Wrist. 


Muscles. 
Flexor  carpi  radialis. 
Extensor  carpi  radialis. 
Extensor  carpi  tilnaris. 
Extensor  longus  pollicis. 


Neeves. 
Median. 
Musculospiral. 
Posterior  interosseous. 
Posterior  interosseous. 


TEST 


223 


Muscle  Action. — This  grouj)  of  muscles  abduct  the  wrist,  that  is, 
turn  the  hand  outward,  away  from  the  midhne. 


Fig.  83. — Forearm  supported  on  table  ulnar  side  down,  attempt  to  abduct  -ssTist. 


Fig.  84. — Forearm  supported  on  table  ulnar  side  down,  attempt  to  adduct  wTist. 

Test.— The  patient  is  seated  with  the  forearm  on  the  table,  ulnar 
side  down,  and  tries  to  abduct  the  ^Tist  by  bringing  it  from  the 


224      EXAMINATION  OF  MUSCLES  AND  MUSCLE   TRAINING 

midline  toward  the  ulnar  side.     The  hand  is  extended  over  the 
edge  of  the  table. 

Exercise. — ^The  patient  in  this  exercise  tries  to  draw  the  wrist 
toward  the  ulnar  side  with  the  arm  resting  on  the  table.  This  may 
be  tried  with  and  without  resistance. 


Group  of  Muscles  which  Adduct  the  Wrist. 


Muscles. 
Flexor  carpi  ulnaris. 
Extensor  carpi  ulnaris. 


Nerves. 
Ulnar. 
Posterior  interosseous. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
adducts  the  wrist — that  is,  draws  the  wrist  toward  the  radial  side. 

Test. — Exactly  as  those  for  abduction,  except  adduction  is  done 
instead  of  abduction. 

Exercise. — Same. 


Group  of  Muscles  which  Flex  the  Fingers. 

Muscles.  Nerves. 


Flexor  digitorum  sublimis. 

Flexor  digitorum  profundus. 

Lumbricales. 

Interossei. 

Flexor  brevis  minimi  digiti. 


Median. 

Anterior  interosseous  and  ulnar. 

Ulnar  and  median. 

Ulnar. 

Ulnar. 


Fig.  85. — Illustrating  flexion  of  fingers. 


Muscle  Action, — Under  normal  conditions  this  group  of  muscles 
flexes  the  fingers  on  the  hand.  In  other  words,  makes  a  fist.  This 
cannot  be  done  if  this  group  of  muscles  is  paralyzed. 


EXERCISE 


225 


Test. — The  patient  is  asked  to  make  a  fist  or  close  the  hand. 

Exercise. — In  this  exercise  the  patient  attempts  to  flex  the  fin- 
gers on  the  hand  by  making  a  fist  and  drawing  the  fingers  toward 
the  pahn  of  the  hand. 

Group  of  Muscles  which  Extend  the  Fingers. 


Muscles. 
Extensor  digit-oruin  communis. 
Extensor  indicis  proprius. 
Extensor  niinimi  digiti. 
Lumbricales. 
luterossei. 


Nerves. 
Posterior  interossei. 
Posterior  interossei. 
Posterior  interossei. 
Median  and  ulnar. 
Ulnar. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
extends  the  fingers  on  the  hand — that  is,  straightens  the  fingers  out. 

Test. — ^The  patient  in  this  test  attempts  to  straighten  the  fingers 
from  a  flexed  position. 


Fig.  86. — Illustrating  extension  of  fingers. 

Exercise. — The  patient  in  this  exercise  tries  to  extend  the  fingers 
either  from  a  flexed  hand  or  a  closed  hand.  He  tries  to  straighten 
the  fingers.  This  may  be  done  with  and  without  resistance  on  the 
part  of  the  examiner. 


Group  of  Muscles  which  Abduct  the  Fingers. 


Muscles. 

Nerves. 

Lumbricales. 

Median  and  ulnar. 

Flexor  brevis  minimi  digiti. 

Ulnar. 

Opponens  minimi  digiti. 

Ulnar. 

Dorsal  interossei. 

Ulnar. 

15 

226      EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

Muscle  Action.- — This  group  of  muscles  under  normal  conditions 
abducts  the  fingers. 

Test. — ^With  the  fingers  adducted — that  is,  together — ask  the 
patient  to  abduct  them  or  to  draw  them  away  from  the  midline. 

Exercise." — ^The  exercise  consists  in  making  the  patient  abduct  the 
fingers  by  bringing  them  away  from  the  midline. 

Group  of  Muscles  which  Adduct  the  Fingers. 

Muscles.  Nerves. 

Palmar  interossei  (to  the  middle  line  of         Ulnar, 
middle  finger). 

Muscle  Action.— This  group  of  muscles  adducts  the  fingers. 
Test.- — Ask  the  patient  to  bring  together  or  adduct  the  fingers. 
Exercise. — In  this  exercise  the  patient  makes  an  attempt  to  adduct 
the  fingers — that  is,  bring  them  together. 

Group  of  Muscles  which  Flex  the  Thumb. 

Muscles.  Nekves. 

Opponens  poUicis.  Median. 

Flexor  brevis  pollicis.  Median. 

Adductor  pollicis.  Ulnar. 

Abductor  pollicis  brevis.  Median. 

Flexor  longus  pollicis.  Anterior  interosseous. 

Muscle  Action. — ^Under  normal  conditions  this  group  of  muscles 
flexes  the  thumb  on  the  hand. 

Test.^ — With  the  thumb  extended  ask  the  patient  to  flex  the  thumb 
on  the  hand. 

Exercise. — The  patient  attempts  in  this  exercise  to  flex  the  thumb 
and  straighten  it  out  again.  This  is  repeated  several  times  and 
may  be  tried  with  and  without  resistance. 

Group  of  Muscles  which  Extend  the  Thumb. 

Muscles.  Nerves. 

Abductor  pollicis  longus.  Median. 

Extensor  pollicis  brevis.  Posterior  interosseous. 

Extensor  pollicis  longus.  Posterior  interosseous. 

Muscle  Action. — This  group  of  muscles,  under  normal  conditions, 
extends  the  thumb. 


EXERCISE  227 

Test.^ — Ask  the  patient  to  draw  the  thumb  backward  toward  the 
dorsal  surface  of  the  hand,  thereby  extending  it. 

Exercise. — In  this  exercise  the  patient  extends  the  thumb  from  a 
flexed  position.     This  may  be  tried  with  and  without  resistance. 

Group  of  Muscles  which  Abduct  the  Thumb. 

Muscles.  Nerves. 

Abductor  pollicis  brevis.  Median. 

Extensor  pollicis  brevis.  Posterior  interosseous. 

Extensor  pollicis  longus.  Posterior  interosseous. 

Muscle  Action. — ^This  group  of  muscles,  under  normal  conditions, 
abduct  the  thumb — that  is,  draw  it  away  from  the  midline  toward 
the  radial  side  of  the  hand. 

Test. — In  this  test  the  patient  is  asked  to  spread  the  thumb  away 
from  the  other  fingers  by  drawing  it  out  from  the  hand. 

Exercise. — ^The  patient  abducts  the  thumb — that  is,  draws  it 
away  from  the  fingers  in  a  lateral  position,  starting  by  having  the 
thumb  adducted  at  first  and  then  abducting  it. 

Circumduction  of  the  thumb  involves  a  combination  of  all  the 
muscles  that  have  as  their  action  the  flexion,  extension,  abduction, 
and  adduction  of  the  thumb. 

Group  of  Muscles  which  Adduct  the  Thumb. 

Muscles.  Nerves. 

Adductor  pollicis  obliquus.  Ulnar. 

Adductor  pollicis  brevis.  Ulnar. 

Adductor  pollicis  transversus.  Ulnar. 

Flexor  pollicis  brevis.  Median. 

Opponens  pollicis.  Median. 

Interosseous  (first  dorsal).  Ulnar. 

Muscle  Action.^ — This  group  of  muscles  adducts  the  thumb — that 
is,  draws  the  thumb  toward  the  midline.  The  thumb  is  inverted, 
so  to  speak. 

Test.— In  this  test  the  patient  is  asked  to  draw  the  thumb  inward 
by  bringing  the  tip  of  the  thumb  to  the  little  finger  at  the  meta- 
carpophalangeal articulation. 

Exercise.^ — ^The  patient  is  asked  to  flex  the  thumb  and  at  the  same 
time  bring  it  toward  the  ulnar  side  of  the  hand.  Inverted,  as 
stated  above. 


228      EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 


Fig.  87. — Illustrating  adduction  of  thumb. 


Group  of  Muscles  which  Flex  the  Spine  Laterally. 


Muscles. 
Erector  spinas  group  mentioned  before, 

plus, 
Rectus  abdominis. 
Obliquus  externus. 
Transversus  abdominis. 
Obliquus  intern  us. 
Psoas  ma.jor  and  minor. 
Quadratus  lumborum. 


Nerves. 


Intercostal,  iljo-inguinal,  iliohypogastric. 
Intercostal,  ilio-inguinal,  iliohypogastric. 
Intercostal,  ilio-inguinal,  iliohypogastric. 
Intercostal,  ilio-inguinal,  iliohypogastric. 
Second  and  third  lumbar. 
Lumbar  and  twelfth  thoracic. 


Muscle  Action. — This  group  of  muscles  bends  the  body  to  the  side 
under  normal  conditions. 

Gait. — ^When  paralysis  of  this  group  of  muscles  occurs,  the  patient 
walks  with  a  scoliosis  and  the  body  flexed  to  the  opposite  side. 

Tests. — 1.  The  patient  lies  on  the  sound  side  with  the  limbs  held 
down  firmly  and  attempts  to  flex  the  body  laterally  to  the  affected 
side. 

2.  The  patient  lies  on  his  back  and  attempts  to  flex  the  body 
toward  the  affected  side  by  trying  to  bend  it  laterally. 

3.  The  patient,  while  standing,  attempts  to  raise  the  foot  of  the 
affected  side  from  the  ground  without  bending  the  knee  or  any 
other  part  of  the  body.    He  tries  to  draw  the  pelvis  up. 

Exercises. — 1.  The  patient  is  placed  in  a  position  on  the  table, 
so  that  the  sound  side  is  down  and  the  affected  side  up.  He  then 
tries  to  flex  the  body  laterally. 


EXERCISES  229 

2.  With  the  patient  lying  on  his  back  an  attempt  is  made  to  flex 
the  body  laterally  toward  the  affected  side. 

3.  If  the  patient  is  able  to  stand,  he  makes  an  attempt  to  raise 
the  foot  of  the  afi'ected  side  from  the  ground  without  bending  the 
knee.  In  this  way  he  raises  the  hip  and  flexes  the  side  aftected,  if 
he  is  able. 

Group  of  Muscles  which  Flex  the  Spine. 

Muscles.  Nerves. 

Rectus  abdominis.  Intercostal,  ilio-inguinal,  iliohypogastric. 

Pyramidalis.  Intercostal,  ilio-inguinal,  iliohypogastric. 

Obliquus  externus.  Intercostal,  ilio-inguinal,  iliohypogastric. 

Obhquus  internus.  Intercostal,  ilio-inguinal,  iliohypogastric. 

Transveisalis  abdominis.  Intercostal,  ilio-inguinal,  iliohypogastric. 

Psoas  major  and  minor.  Second  and  third  lumbar. 

Sartorius.  Anterior  crural. 

Iliacus.  Anterior  crural. 

Psoas.  Anterior  crural. 

Pectineus.  Anterior  crural. 

Rectus  femoris.  Anterior  crural. 

Adductor  longus.  Obturator. 

Gracilis.  Obturator. 

Obturator  externus.  Obturator. 

Muscle  Action.- — Under  normal  conditions  this  group  of  muscles 
flexes  the  spine — that  is,  bends  the  body  forward. 

Gait. — In  this  condition  the  patient  is  unable  to  walk  without 
his  abdomen  protruding  and  the  hips  flexed.  There  is  a  marked 
lordosis  present  which  appears  a  little  later. 

Tests. — 1.  Have  the  patient  lie  down  with  his  arms  folded,  in  a 
sort  of  semireclining  postm-e,  and  then  make  an  attempt  to  sit  up 
if  he  is  able  to  do  so.  His  knees  must  be  held  down  while  this  test 
is  tried. 

2.  The  patient  lies  flat  with  his  arms  folded  and  from  this  posi- 
tion tries  to  sit  up  straight. 

3.  The  patient  lies  on  his  back  and  attempts  to  flex  the  knees 
on  the  chest. 

Exercises.^ — 1.  The  patient,  in  this  exercise,  lies  down  in  a  sort  of 
semireclining  position  on  a  back  rest  which  is  slanting,  or  a  board, 
and  attempts  to  assume  an  upright,  sitting  posture. 

2.  In  the  flat  position  the  patient  attempts  the  exercise  as 
described  in  the  test  above  by  trying  to  sit  up  from  this  position. 

3.  With  the  patient  lying  on  his  back,  an  attempt  is  made  to  flex 
the  thighs  on  the  chest. 


230      EXAMINATION  OF  MUSCLES  AND  MUSCLE   TRAINING 

4.  In  this  exercise  the  patient  lies  on  his  side  with  arms  folded 
and  hips  held  down  and  attempts  to  flex  the  spine  by  bringing  the 
body  forward.  This  may  be  tried  first  on  one  side  and  then  on  the 
other. 


Fig.  88. 


-Series  No.  I.     Flexion  of  spine.     Patient  lying  down  with 
knees  held  and  arms  folded  attempts  to  sit  up. 


Fig.  89. — Second  position. 


Fig.  90.— Third  position. 


EXERCISES 


231 


Fig.   91. — Fourth  position. 


Fig.  92. — Fifth  position.     Flexion  completed. 


Group  of  Muscles  which  Extend  the  Spine. 


Muscles. 
(Cunningham). 
Serratus  posterior. 
Splenius  capitis. 

Splenius  cervicis. 

Sacrospinalis. 

Semispinalis  dorsi. 

Semispinalis  cervicis. 

Semispinalis  capitis. 

Multifidus. 

Interspinalis. 

Intercostal. 

Diaphragm. 

Trans  versus  thoracis. 


Nerves. 

Intercostal. 

External    posterior    branch    of    second 

cervical. 
External    posterior    branch    of    second 

cervical. 
External   posterior   branch,    sacral   and 

lumbar. 
Internal  branch  of  cervical  plexus. 
Branches  of  cervical  nerves. 
Branches  of  cervical  nerves. 
Branches  of  cervical  nerves. 
Internal  posterior  branch  of  spinal  nerves. 
Intercostal. 
Phrenic. 
Intercostal. 


232      EXAMINATION  OF  MUSCLES  AND  MUSCLE   TRAINING 


This  group  of  muscles  includes  the  muscles  which  are  sometimes 
spoken  of  as  the  erector  spinse  group. 

Muscle  Action. — ^These  muscles,  together  with  the  extensor  muscles 
of  the  thigh,  extend  the  spine — that  is,  bend  the  body  backward. 

Gait.— A  patient  with  paralysis  of  these  muscles  can  neither 
stand,  sit  nor  walk. 

Tests.^ — 1.  The  patient  lies  face  downward  on  a  table  or  bed  and 
in  this  position  tries  to  raise  the  body  from  the  table  by  extension. 

2.  The  patient  sits  with  the  body  bent  forward  and  in  this  posi- 
tion attempts  to  straighten  the  body  by  sitting  upright.  This  test 
may  be  tried  with  the  assistance  of  the  hands  on  the  hips  and 
thereby  assisting  or  without  it. 

Exercises. — 1.  The  patient  lies  face  downward  as  in  the  test  and 
attempts  to  raise  the  body  from  the  table. 

2.  In  this  second  exercise  the  patient,  after  having  bent  the 
body  forward,  tries  to  sit  up  straight. 

Group  of  Muscles  which  Abduct  the  Thigh  on  the  Trunk. 


Muscles. 
Tensor  fascia  femoris. 
Gluteus  medius. 
Gluteus  minimus. 

Obturator  externus  (during  flexion). 
Pyriformis. 
Obturator  internus. 
Gemelli. 
Sartorius. 
Gluteus  maximus  (upper  fibers). 


Nerves. 
Superior  gluteal. 
Superior  gluteal. 
Superior  gluteal. 
Obturator. 
Sacral  plexus. 
Sacral  plexus. 
Sacral  plexus. 
Anterior  crural. 
Inferior  gluteal. 


Fig.  93. — Patient  lying  on  unaffected  side  abducts  hip  by  raising  leg 
with  knee  straight. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
abducts  the  thigh  on  the  trunk.     (Some  of  the  muscles  concerned 


EXERCISES 


233 


have,  in  addition,  anotlier  action  which  will  })e  found  under  other 
headings.) 

Tests. — 1.  The  patient  lies  on  the  good  side  and  attempts  to  raise 
the  leg  of  the  affected  side  laterally  from  the  line  of  the  body. 

2.  The  patient  lies  on  his  back  and  attempts  to  abduct  the  leg 
and  thigh  by  drawing  it  outward  on  a  line  with  the  body. 

Exercises. — 1.  The  patient,  while  lying  on  the  unaffected  side, 
attempts  the  abduction  of  the  thigh  with  and  without  resistance. 

2.  The  patient  lies  on  his  back  and  attempts  to  abduct  the  thigh, 
the  pelvis  being  held  firmly  to  keep  it  from  moving. 


Gkoup  of  Muscles  which  Adduct  the  Thigh  on  the  Trunk. 

Muscles.  Nerves. 


Adductor  longus. 

Adductor  brevis. 

Adductor  magnus. 

Pectineus. 

Gracilis. 

Quadratus  femoris. 

Gluteus  maximus  (lower  fibers). 


Obturator. 

Obturator. 

Branch  of  great  sciatic. 

Anterior  crural. 

Obturator. 

Branch  of  sacral  plexus. 

Inferior  gluteal. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
adducts  the  thigh  from  the  midline. 

Gait. — In  walking,  if  the  patient  places  one  foot  in  front  of  the 
other  he  will  swing  the  body  with  each  step. 

Test. — The  patient  lies  on  his  back  with  the  leg  abducted  and 
attempts  to  bring  it  to  the  midline. 

Exercises.^ — 1.  The  patient  assumes  the  position  on  his  back  and 
attempts  to  bring  the  leg  toward  the  midline  after  it  has  been 
abducted.    This  may  be  done  with  and  without  resistance. 

2.  The  patient  in  this  exercise  lies  flat  on  his  back  with  the  knees 
flexed,  the  soles  of  his  feet  flat  on  the  table,  and  the  knees  spread 
apart.  In  this  position  he  makes  the  attempt  to  bring  the  knees 
together  with  and  without  resistance. 


Group  of  Muscles  which   Flex  the  Thigh  on  the  Trunk. 


Muscles. 
Sartorius. 
Iliacus. 
Psoas. 
Pectineus. 
Rectus  femoris. 
Adductor  longus. 
Gracilis. 
Obturator  extcrnus. 


Nerves. 


Anterior  crural. 
Anterior  crural. 
Anterior  crural. 
Anterior  crural. 
Anterior  crural. 
Obturator. 
Obturator. 
Obturator. 


234      EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
flexes  the  thigh  on  the  trunk. 

Gait. — In  attempting  to  walk  the  patient  swings  the  entire  pelvis 
of  the  affected  side  forward  in  order  to  bring  the  leg  and  thigh 
forward.     This  produces  a  condition  of  lordosis  in  a  short  while. 


Fig.  94. — Patient  seated  attempts  flexion  of  thigh.    Resistance  offered  against  knee. 


Fig.  95. — Patient  lying  on  affected  side  attempts  flexion  of  thigh.     Sound 
leg  held  up  and  out  of  the  way. 


Tests. — 1.  With  the  patient  lying  on  his  back  an  attempt  is  made 
by  him  to  bring  the  knee  up  to  the  chest  in  an  endeavor  to  flex 
the  thigh. 


EXERCISES  235 

2.  The  patient  may  be  seated  with  his  leg  hanging  over  the  bed 
or  table  and  an  attempt  is  made  to  flex  the  thigh. 

3.  The  patient  may  lie  on  the  affected  side  and  attempt  to  flex 
the  thigh.    In  this  test  the  good  leg  should  be  held  out  of  the  way. 

Exercises. — 1.  With  the  patient  on  his  back  the  exercise  of  draw- 
ing the  knee  up  to  the  chest  and  thereby  producing  flexion  may  be 
tried. 

2.  With  the  patient  seated  the  flexion  of  the  thigh  by  bringing 
the  knee  to  the  chest  is  a  splendid  exercise. 

3.  With  the  patient  lying  on  his  side  and  the  unaffected  limb 
held  up  and  out  of  the  way,  flexion,  by  drawing  the  knee  up  to  the 
chest  is  another  exercise.  In  this  some  resistance  may  be  offered 
by  the  examiner. 

Group  of  Muscles  which  Extend  the  Thigh  on  the  Trits'k. 

Muscles.  Nerves. 

Gluteus  maximus.  Inferior  gluteal. 

Gluteus  medius.  Superior  gluteal. 

Gluteus  minimus.  Superior  gluteal. 

Biceps  femoris.  Great  sciatic  and  external  popliteal. 

Semitendinosus.  Branch  of  great  sciatic. 

Semimembranosus.  Branch  of  great  sciatic. 

Adductor  magnus.  Branch  of  great  sciatic  and  obturator. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
extends  the  thigh  on  the  trunk. 

Gait. — In  this  condition,  if  the  patient  attempts  to  walk,  he 
walks  wdth  a  limp,  due  to  the  fact  that  the  foot  of  the  affected  side 
touches  the  ground  very  lightly  and  the  good  leg  is  brought  forward 
rapidly.  The  good  leg  or  unaffected  leg  is  bent  at  the  knee  in 
walking. 

Tests. — 1.  The  patient  may  lie  on  the  table  face  dow^nward  and 
an  attempt  should  be  made  to  hyperextend  the  hip  with  the  thigh 
and  leg  straight  by  lifting  the  leg  from  the  table  or  bed.  This  test 
can  also  be  tried  by  having  the  patient  lying  on  the  table  and 
allowing  his  thighs  and  legs  to  hang  over  the  edge.  In  this  position 
he  maA'  try  to  extend  the  thigh  with  the  knee  straight. 

2.  The  patient  lies  on  the  affected  side  with  his  hip  flexed  and 
makes  an  attempt  to  straighten  the  thigh  and  extend  it  in  line  with 
the  body. 

Exercises. — 1.  The  patient  in  this  exercise  lies  on  his  face  and 
attempts  to  raise  the  entire  leg  from  the  table  or  bed  in  hj-per- 


236      EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

extension  by  bringing  the  leg  up  from  the  table.     This  may  be 
exercised  with  and  without  resistance. 

2.  Patient  assumes  the  attitude  of  allowing  the  lower  part  of 
the  body  to  hang  over  the  table — that  is,  the  thigh  and  leg.  An 
attempt  is  made  to  bring  the  leg  up  on  a  line  with  the  body. 


Fig.  96. — Patient  lying  on  face  attempts  extension  of  hips  against  resistance. 

3.  The  patient  can  assume  the  position  of  lying  on  the  affected 
side  with  the  thigh  flexed.  The  unaffected  side  is  held  out  of  the 
way  and  an  attempt  is  made  to  extend  the  leg  and  bring  it  in  line 
with  the  body. 

4.  The  patient  lies  on  his  back  and  the  knee  is  straightened.  The 
entire  leg  is  then  raised  by  the  examiner  from  the  table  or  bed  and 
the  patient  attempts  to  bring  it  down  with  some  resistance  being 
offered. 


Group  of  Muscles  which  Rotate  the  Thigh  Outward. 


Muscles. 
Gluteus  maximus  (lower  fibers). 
Gluteus  medius  (posterior  fibers). 
Gluteus     minimus     (posterior    fibers). 

During  extension. 
Quadratis  femoris. 
Pyriformis. 
Gemelli. 

Obturator  externus. 
Sartorius. 
Iliopsoas. 
Pectineus. 
Adductor  longus. 
Adductor  brevis. 
Adductor  femoris. 
Biceps  femoris. 


Nerves. 
Inferior  gluteal. 
Superior  gluteal. 
Superior  gluteal. 

Sacral  plexus. 

Sacral  plexus. 

Sacral  plexus. 

Obturator. 

Anterior  crural. 

Anterior  crural. 

Anterior  crural. 

Obturator. 

Obturator. 

Obturator. 

Great  sciatic  and  external  popliteal. 


EXERCISES 


237 


Muscle  Action. — lender  normal  conditions  this  group  of  muscles 
rotates  the  thigh  outward. 

Tests. — 1.  The  patient  lies  flat  on  his  back  with  legs  and  thighs 
straightened  out  and  attempts  to  rotate  the  thigh  outward.  The 
pelvis  must  be  held. 

2.  The  patient  sits  on  the  side  of  the  table  or  bed  with  knees 
flexed  and  hanging  oxev.  In  this  position  he  crosses  the  foot  of  the 
affected  side  over  the  sound  side  and  rotates  the  thigh  out\\-ard  by 
twisting. 

Exercises. — 1.  The  patient  attempts  the  crossing  over  of  the 
affected  side  and  the  rotation  outward  of  the  thigh  by  twisting, 
with  and  without  resistance. 


Fig.  97. — Patient  seated  attempts  outward  rotation  of  hip.     Resistance  offered 
on  inner  side  of  leg. 

2.  With  the  patient  flat  on  his  back  he  attempts  the  rotating 
outward  of  the  thigh,  the  pelvis  being  held  to  keep  it  from  twisting. 
This  mav  be  done  with  and  without  resistance. 


Group  of  ]\Iuscles  wtiich  Rotate  the  Thigh  In^'ard. 

MuscLE.s.  Nerves. 


Tensor  fascia  femoris. 

Gluteus  medius  (anterior  fibers). 

Gluteus  minimus  (anterior  fibers). 

Semimembranosus. 

Semitendinosus. 

Gracilis? 

Iliopsoas? 


Superior  gluteal. 
Superior  gluteal. 
Superior  gluteal. 
Branch  of  great  sciatic. 
Branch  of  great  sciatic. 
Obturator. 
Anterior  crural. 


238      EXAMINATION  OF  MUSCLES  AND  MUSCLE   TRAINING 

Muscle  Action. — This  group  of  muscles,  under  normal  conditions, 
rotates  the  thigh  inward.  These  muscles  also  have  some  other 
action,  the  rotation  being  only  a  part  of  their  entire  action. 


Fig.  98. 


-Ptitient  seated  attempts  inward  rotation  of  hip. 
offered  on  outer  side  of  leg. 


Resistance 


Test. — The  patient  lies  on  his  back  and  attempts  to  rotate 
the  whole  leg  inward.  In  order  to  have  an  accurate  test  the  foot 
of  the  affected  side  should  be  rotated  outward  before  this  test  is 
attempted. 

Exercise. — ^The  patient  attempts  the  inward  rotation  of  the  thigh 
and  leg  with  and  without  resistance  while  lying  on  his  back. 


Group  of  Muscles  which  Flex  the  Knee. 


Muscles. 
"  Hamstrings." 
Sartorius. 
Gracilis. 
Semitendinosus. 
Semimembranosus. 
Biceps  femoris. 
Gastrocnemius. 
Plantaris. 
Popliteus. 


Nerves. 

Anterior  crural. 

Obturator. 

Branch  of  great  sciatic. 

Branch  of  great  sciatic. 

Great  sciatic  and  external  (popliteal). 

Internal  popliteal. 

Internal  popliteal. 

Internal  popliteal. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
flexes  the  knee  on  the  thigh. 


EXERCISES 


239 


Gait. — If  this  group  of  muscles  is  paralyzed  the  patient  walks 
with  the  leg  extended  and  the  foot  brought  down  forcibly.  No 
flexion  takes  place  in  walking. 

Tests. — 1.  The  patient  lies  on  the  table  face  downward  and  tries 
to  flex  the  knee  by  bringing  the  heel  up. 


Fig.  99. — Attempt  to  flex  knee.     Resistance  offered  by  examiner. 

2.  The  patient  lies  on  the  side  affected  and  tries  to  flex  the  knee 
by  bringing  the  leg  up.  The  thigh  must  be  held  tightly  while  this 
test  is  made. 


Fig.  100. — Patient  lying  on  back  attempts  to  flex  knee  against  resistance. 

Exercises. — 1.  The  patient  assumes  the  same  position  as  in  the 
test  and  attempts  to  flex  the  knee  by  bringing  the  leg  up.  This 
exercise  may  be  aided  first  with  assistance  and  later  resistance. 

2.  The  patient,  on  his  affected  side,  attempts  flexion  of  the  knee 
while  the  thigh  is  held  firmly  on  the  table.    In  this,  as  in  the  preced- 


240     EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

ing   exercise,    the   examiner   can   assist   or   resist   the   movement 
attempted. 

3.  The  patient  hes  on  his  back  and  the  examiner  holds  the  thigh 
up  in  order  to  allow  the  patient  to  attempt  flexion  of  the  leg.  In 
this  exercise  gravity  and  weight  of  the  leg  help  in  attempting  the 
flexion. 


Group  of  Muscles  which  Extend  the  Knee. 

Muscles.  Nerves. 


Quadriceps  extensor. 
Vastus  externus. 
Vastus  internus. 
Crureus. 
Rectus  femoris. 


Anterior  crural. 

Anterior  crural. 
Anterior  crural. 
Anterior  crural. 


Muscle   Action. — Under  normal  conditions    the  muscles  in  this 
group  extend  the  leg. 


Fig.  101. 


-First  step  in  extension  of  knee.     Patient  seated  on  heel  of  affected 
side  attempts  to  rise.     Assistance  by  examiner. 


Gait. — If  these  muscles  are  paralyzed  the  leg  is  in  a  condition  of 
flexion  and  the  patient  cannot  walk  unless  he  supports  the  thigh 
anteriorly  with  his  hand  or  with  hyperextension,  thereby  locking 
the  knee. 

Tests. — 1.  The  patient,  if  possible,  tries  to  sit  on  his  heels  in  a 
squatting  position  and  tries  to  raise  himself  by  putting  all  the  weight 
on  the  affected  leg. 

2.  The  patient  is  seated  with  the  leg  hanging  over  the  side  of 
the  bed  or  table  and  tries  to  extend  the  leg  from  a  flexed  position. 


EXERCISES 


241 


3.  The  patient  can  also  be  tested  in  the  lying   position,  if  an 
attempt  is  made  to  extend  the  leg. 


Fig.  102. — Second  step  in  extension  of  knee.     Patient  has  raised  himself 
on  affected  side. 

Exercises.. — 1.  If  the  patient  is  able  to  sit  in  the  squatting  posi- 
tion and  can  try  to  raise  himself,  this  exercise  may  be  tried. 


Fig.    103. — Attempt  to  extouJ  kn(.'e.      Rcbidiance  offered  by  examiner. 

2.  Seated  on  the  side  of  the  table  or  bed  with  the  leg  flexed,  he 
should  attempt  to  extend  the  leg  with  and  without  resistance  and 
assistance  of  the  examiner's  hand. 
16 


242     EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

3.  The  patient  can  lie  on  the  side  affected  or  else  face  down  and 
attempt  extension  of  the  leg  from  a  flexed  position  of  the  knee. 

Group  of  Muscles  which  Dorsal  Flex  the  Foot  on  the  Leg. 

Muscles.  Nerves. 

Tibialis  anticus.  Anterior  tibial. 

Peroneus  tertius.  Anterior  tibial. 

Extensor  proprius  hallucis.  Anterior  tibial. 

Extensor  longus  digitorum.  Anterior  tibial. 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
govern  the  dorsal  flexion  of  the  foot  on  the  leg. 

Gait. — A  person  with  paralysis  of  this  group  of  muscles  is  unable 
to  walk  in  the  usual  manner  and  a  peculiarity  of  gait  is  noticed. 
This  is  seen  when  the  patient  attempts  to  walk  and  at  this  time 
the  affected  limb  will  be  lifted  high  off  the  ground  in  order  to  pre- 
vent the  dragging  of  the  toes. 


Fig.   104. — Illustrating  dorsal  flexion  of  foot. 

Tests. — 1.  If  the  patient  is  able  to  stand  have  him  attempt  to 
raise  the  front  part  of  the  affected  foot  off  the  ground.  If  any 
paralysis  is  present  he  will  be  unable  to  do  this  and  in  addition  he 
cannot  stand  on  the  heel  of  the  side  which  is  paralyzed. 

2.  After  this  test  has  been  tried  or  if  the  patient  cannot  stand, 
this  second  test  is  useful.  In  this  the  patient  is  seated  on  the  side 
of  the  bed  or  table  with  the  feet  hanging  over  the  side.  The  patient 
should  now  attempt  to  flex  the  foot  on  the  leg  dorsally,  first  with- 
out resistance  on  the  part  of  the  examiner  and  then  with 
some  resistance,  by  placing  the  examiner's  hand  on  the  dorsum  of 
the  foot  and  estimating  the  strength  of  the  attempted  flexion. 


MUSCLE  ACTION 


243 


3.  In  this  test  the  patient  Hes  on  the  affected  side  and  attempts 
to  flex  the  foot  with  and  without  resistance.  The  operator  must 
hold  the  leg  on  the  table  tightly,  in  order  to  prevent  any  other 
muscle  movement. 

Exercises. — 1.  If  the  patient  can  stand,  have  him  attempt  to  raise 
the  foot  in  dorsal  flexion  by  allowing  the  heel  to  remain  on  the 
ground. 

2.  The  patient  should  lie  on  the  affected  side  and  with  the  leg 
held  firmlv  he  should  try  to  flex  the  foot  on  the  leg. 


Fig.   105. — Attempt  at  dorsal  flexion  of  foot.     Resistance  by  examiner. 

3.  The  patient  assumes  a  position  on  the  table  or  bed  with  his 
face  downward.  In  this  position  the  knee  is  flexed  at  right  angles 
and  the  leg  vertically  directed.  An  attempt  should  be  made  by 
the  patient  to  flex  the  foot  on  the  leg  with  and  without  resistance. 


Group  of  JNIuscles  which  Plantar  Flex  the  Foot  on  the  Leg. 


Muscles. 
Gastrocnemius. 
Soleus. 
Plantaris. 
Tibialis  posticus. 
Flexor  longus  hallucis. 
Flexor  longus  digitorum. 
Peroneus  longus. 
Peroneus  brevis. 


Nerves. 
Internal  popliteal. 
Internal  popUteal. 
Internal  popliteal. 
Posterior  tibial. 
Posterior  tibial. 
Posterior  tibial. 
Musculocutaneous. 
Musculocutaneous. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
govern  the  plantar  flexion  of  the  foot  on  the  leg. 


244     EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

Gait. — In  walking  the  patient  will  attempt  to  walk  on  the  flat 
part  of  the  foot,  or  more  likely  on  the  heel  with  the  toes  elevated, 
if  any  paralysis  of  this  group  of  muscles  is  present. 

Tests. — 1.  If  the  patient  is  able  to  stand,  have  him  stand  on  the 
foot  affected  and  try  to  raise  himself  on  the  toes  of  this  foot.  In 
case  this  group  of  muscles  is  affected  he  cannot  do  this. 

2.  Let  the  patient  try  to  walk  on  the  toes  of  the  affected  side. 

3.  If  the  patient  cannot  stand,  have  him  lie  face  downward  and, 
with  the  foot  extended  over  the  edge  of  the  table  or  bed,  let  him 
attempt  to  plantar  flex  the  foot  with  and  without  resistance. 

4.  The  patient  lies  on  the  affected  side  and  tries  plantar  flexion 
with  the  leg  held  firmly  on  the  table  by  the  examiner.  This  may 
be  done  with  and  without  assistance. 


Fig.  106. — Illustrating  plantar  flexion  of  foot. 

Exercises.— 1.  If  the  patient  can  stand,  have  him  attempt  to  raise 
up  on  the  toes  of  the  affected  side  and  exercise  the  paralyzed 
muscles  in  this  way. 

2.  Let  the  patient  lie  down  and  attempt  plantar  flexion  with 
and  without  assistance. 

3.  The  patient  may  also  exercise  plantar  flexion  lying  on  his 
side,  meaning  the  affected  side.  This  may  also  be  tried  with  and 
without  assistance. 

Group  of  Muscles  which  Invert  the  Foot. 

Muscles.  Nebves. 

Tibialis  anticus.  Anterior  tibial. 

Tibialis  posticus.  Posterior  tibial. 

Muscle  Action. — Under  normal  conditions  these  muscles  invert 
the  foot  on  the  leg. 


EXERCISE  245 

Gait. — In  case  of  paralysis  of  the  muscles  which  cause  inversion 
of  the  foot  the  patient  walks  on  the  inner  border  of  the  paralyzed 
foot  with  the  sole  of  the  foot  turned  outward.  This  condition  is 
called  talipes  valgus. 

Test. — The  patient  is  seated  with  the  leg  hanging  over  the  side 
of  the  table  or  bed  and  then  tries  to  tiun  the  sole  of  the  foot  inward 
while  the  examiner  holds  the  leg  tightly. 


Fig.  107. — Inversion  of  foot.    Leg  held  by  examiner. 

Exercise. — ^The  patient  in  doing  this  exercise  is  seated  with  the 
foot  hanging  over  the  side  of  the  table  or  bed  and  attempts  to  invert 
the  sole  of  the  foot  with  and  without  resistance  on  the  part  of  the 
examiner.  The  resistance  in  this  case  is  offered  by  placing  the  hand 
on  the  sole  of  the  foot  and  trying  to  prevent  the  inversion  of  the 
foot.  Sometimes  it  is  best  to  start  this  exercise  by  giving  the 
patient  a  little  help  in  carrying  out  this  movement.  [This  may  also 
be  done  with  the  patient  lying  on  his  back  and  the  leg  supported 
by  the  examiner. 

Group  of  Muscles  which  Evert  the  Foot. 

Muscles.  Nerve  Innervation. 

Peroneus  tertius.  Anterior  tibial. 

Peroneus  longus.  Musculocutaneous. 

Peroneus  brevis.  Musculocutaneous. 


246     EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
everts  the  foot. 

Gait. — In  case  of  paralysis  of  this  group  of  muscles  which  cause 
eversion  of  the  foot  the  patient  walks  on  the  outer  border  of  the 
foot  which  is  paralyzed  and  the  sole  is  turned  inward.  This  condi- 
tion is  called  talipes  varus. 

Test. — ^The  patient  is  seated  with  the  leg  hanging  over  the  side 
of  the  table  or  bed  and  then  tries  to  turn  the  sole  of  the  foot  outward 
while  the  examiner  holds  the  leg  tightly. 

Exercise. — In  doing  this  exercise  the  patient  is  in  the  same  posi- 
tion as  for  the  one  in  which  inversion  is  attempted.  He  is  seated 
at  the  side  of  the  table  or  bed  with  the  leg  hanging  over  and  attempts 
to  evert  the  foot  by  turning  it  outward.  This  may  be  done  with 
and  without  assistance  and  resistance  by  the  examiner.  The  patient 
may  try  this  exercise  lying  down. 


Group  of  Muscles  which  Flex  the  Toes. 

Muscles.  Nerve  Innervation. 


Flexor  longus  digitorum. 
Flexor  longus  hallucis. 
Flexor  brevis  hallucis. 
Flexor  brevis  digitorum. 
Flexor  brevis  minimi  digiti. 
Lumbricales. 
Interossei. 
Accessorius. 


Posterior  tibial. 

Posterior  tibial. 

Internal  plantar. 

Internal  plantar. 

External  plantar. 

External  and  internal  plantar. 

External  plantar. 

External  plantar. 


Fig.  108. — "Making  a  fist  with  foot."     Flexion  of  toes. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
flexes  the  toes  in  plantar  flexion. 

Tests. — The  patient  either  lies  down  or  is  seated,  and  in  this 
position  tries  to  flex  the  toes — that  is,  draw  them  toward  the  sole 
of  the  foot.  The  patient  may  understand  more  clearly  if  he  is  told 
to  make  a  fist  with  his  toes. 


THE  SPRING-BALANCE  MUSCLE  TEST 


247 


Exercises. — To  exercise  the  paralysis  of  these  muscles  the  patient 
is  placed  in  the  same  position  as  in  the  test.  He  should  attempt 
to  flex  the  toes  in  the  plantar  direction,  first  without  any  resistance, 
and  then  with  resistance  of  the  hand  of  the  examiner,  who  pushes 
against  the  toes  while  the  patient  attempts  to  flex  them. 

Group  of  Muscles  which  Extend  the  Toes. 


Muscles. 
Extensor  longus  digitorum. 
Extensor  brevis  digitorum. 
Extensor  longus  hallucis. 


Xerve  Ix.vervatiox. 
Anterior  tibial. 
Anterior  tibial. 
Anterior  tibial. 


Muscle  Action. — Under  normal  conditions  this  group  of  muscles 
extends  the  toes  by  raising  them. 

Test. — The  patient  either  lies  down  or  is  seated  and  then  tries 
to  extend  the  toes  by  drawing  them  up  toward  the  dorsum  of  the 
foot. 


Fig.   109. — Attempt  to  extend  toes  against  resistance. 

Exercise. — The  patient  is  seated  with  the  legs  hanging  over  the 
side  of  the  bed  or  table  and  in  this  position  he  should  attempt  to 
extend  the  toes  with  and  without  resistance.  Resistance  in  this 
exercise  is  given  by  the  examiner  placing  his  hand  on  the  dorsum 
of  the  foot  and  pressing  down  while  the  patient  attempts  extension. 
This  may  also  be  tried  with  the  patient  lying  down. 


THE    SPRING-BALANCE   MUSCLE    TEST. 

The  spring  balance  muscle  test  was  devised  by  Lovett  and 
Martin,^  of  Boston,  and  has  been  used  by  them  very  extensively 
over  a  period  covering  almost  two  years.  It  is  used  to  estimate  the 
strength  of  muscle  groups  and  not  only  indi\idual  muscles.     This 

1  Am.  Jour.  Orthop.  Surg.,  July,  191G. 


248     EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

test  is  of  value  not  only  in  the  examination,  but  also  in  the  diag- 
nosis and  study  of  the  disease.  When  this  work  was  first  started 
by  these  two  observers  the  classification  of  muscles  was  rather 
unsatisfactory  and  at  the  same  time  unreliable.  Muscles  were 
classified  according  to  the  amount  of  movement  as  normal,  partly 
paralyzed,  or  completely  paralyzed,  depending  on  their  power  of 
contraction.  It  can  readily  be  seen  that  as  far  as  the  first  and  last 
groups  are  concerned  very  little  difficulty  was  experienced  in  group- 
ing the  normal  and  completely  paralyzed  groups;  but  the  real  diffi- 
culty was  found  to  be  in  the  class  of  partially  paralyzed  muscles. 


^jm  ^^\ 

# 

/                              ^BBJiS 

Hi.  ^^^^H 

t     ,  1 

WKmtK0^^^^ 

tel 

Fig.  110. — Test  for  hip  flexion.     Courtesy  of  Lovett  and  Martin  (American  Journal 
of  Orthopedic  Surgery,  JuJy,  1916). 


To  this  class  belonged  everything  from  an  almost  normal  muscle 
contraction  to  one  almost  paralyzed,  and  little  distinction  could 
be  made.  Since  the  advent  of  this  test,  however,  a  way  has  been 
found  to  give  us  not  only  the  qualitative  estimation  or  value  of  a 
muscle  or  group  but  also  the  quantitative  value,  which  in  itself  is 
of  utmost  importance,  especially  as  far  as  the  subsequent  treat- 
ment is  concerned.  In  this  treatment  it  has  entered  the  vacancy, 
so  long  open,  for  giving  us  an  idea  concerning  especially  the  improve- 
ment or  progressive  muscular  failure,  which  we  have  been  unable 
to  estimate  in  any  satisfactory  way  up  to  the  time  of  the  devising 
of  this  test. 


THE  HPRINd-BALANCE  MUSCLE   TEST 


249 


In  order  to  give  an  accurate  description  we  quote  from  the  reprint 
of  Lovett  and  Martin: 

"The  method  is  designed  to  test,  under  conditions  of  constant 
position  and  leverage,  by  a  series  of  spring-balance  pulls,  the  power 
of  the  muscles  which  govern  the  movement  of  the  limbs.  The 
value  of  the  test  consists  in  the  possibility  of  duplicating  exactly 
the  conditions  of  the  first  test  at  succeeding  ones,  so  that  a  definite 
idea  of  gain  or  loss  in  muscular  strength  can  be  registered  in 
pounds.  It  is  applicable  for  all  tests  of  power  in  normal  muscles, 
for  determining  loss  or  gain  in  power  at  stated  intervals,  and  for 
determining  of  the  degree  of  initial  weakness  in  paralyzed  muscles. 


Fig.  111. — Apparatu.s  used  in  muscle  test.  The  numbers  in  the  illustration  are 
referred  to  in  the  text.  Courtesy  of  Lovett  and  Martin  (American  Journal  of 
Orthopedic  Surgery,  July,  1916). 


"The  accuracy  of  the  test  depends  upon  the  training  of  two  per- 
sons, an  operator  and  an  assistant,  to  coordinate  the  pull  of  the 
muscle  and  the  registration  of  the  pull  on  the  scales,  and  upon  the 
maintenance  with  exactness  of  the  positions  and  leverage  relation- 
ship individually  below.  Accurate  spring-balance  scales  (No.  5  in 
Fig.  1)  are  used  of  four  sizes:  1-4  pounds,  graded  in  ounces;  1-30 
pounds,  1-50  pounds,  and  1-100  pounds.  The  readings  are  taken 
to  the  half-pound,  except  on  the  ounce  scale. 

"The  operator  in  general  controls  and  maintains  the  correct 
position  of  the  subject,  stimulates  the  subject  to  innervation,  braces 
and  guides  the  limb  tested,  and  calls  the  moment  of  give  in  the 
muscle  tested  through  watching  the  action  of  the  muscle  itself.  The 
assistant  makes  the  pull  along  lines  accurately  determined,  begin- 


250     EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

ning  and  stopping  under  the  direction  of  the  operator.  The  same 
command  directs  the  muscular  pull  of  the  patient  and  the  scale 
pull  of  the  assistant.  In  all  cases  in  which  the  position  of  the 
assistant  makes  this  possible  the  scale  reading  is  taken  by  him  at 
the  moment  when  the  yielding  in  the  muscle  is  called  by  the  oper- 
ator. Except  under  special  circumstances,  plantar  flexion  is  the 
only  reading  which  the  operator  is  required  to  make. 

"Twenty-two  readings  are  taken,  for  each  of  which  the  best 
position  of  the  subject  for  the  accurate  reading  of  the  scales  and 
for  constant  leverage  in  the  limb  action  has  been  determined 
experimentally." 

In  describing  the  various  measurements  the  numbers  used  in  the 
illustrations  will  be  referred  to.  It  may  be  stated  here  that  the 
following  records  of  movements  are  taken.  It  is  best  to  take  these 
in  some  definite  order  so  that  they  may  be  duplicated  at  a  subse- 
quent examination: 


Lower  Extremitt. 


Plantar  flexion  of  foot. 
Dorsal  flexion  of  foot. 
Inversion  of  foot. 
Eversion  of  foot. 
Adduction  of  foot. 
Abduction  of  foot. 
Extension  of  hip. 
Flexion  of  hip. 
Extension  of  knee. 
Flexion  of  knee. 


Upper  Extremity. 

Pectoralis  muscle. 
Latissimus  dorsi  muscle. 
Anterior  deltoid  muscle. 
Posterior  deltoid  muscle. 
Extension  of  forearm. 
Flexion  of  forearm. 
Extension  of  wrist. 
Flexion  of  wrist. 
Extension  of  fingers. 
Flexion  of  fingers. 
Adduction  of  thumb. 


Quotations  of  a  few  of  the  many  tests  follows,  the  mode  of 
procedure  being  that  described  by  Lovett  and  Martin  in  their 
article : 

"  Plantar  Flexion. — The  patient  lies  on  his  back  on  a  table  and 
braces  his  foot  against  a  three-to-one  lever  (No.  1).  The  hook  of 
the  scale  is  inserted  into  the  ring  of  the  lever  upright.  The  lever 
must  be  so  adjusted  that  the  ball  of  the  foot  in  maximum  plantar 
flexion  rests  squarely  upon  the  lever  pad  (No.  2),  with  the  upright 
at  an  angle  of  from  60  to  80  degrees  to  the  table.  The  lever  is 
held  in  position  by  C  clamps  (No.  3).  The  pull  is  made  by  the 
assistant  from  the  head  of  the  table,  with  the  scale  hor  zontal  and 
in  line  with  the  leg  being  tested,  and  is  increased  in  intensity  to  the 
point  where  the  muscular  resistance  is  overcome.  To  prevent 
slipping  on  the  table  the  shoulders  of  the  subject  are  being  held  by 
the  hip-braces  (No.  4).    The  muscle  gives  at  about  45  degrees  of 


THE  SPRING-BALANCE  MUSCLE  TEST  251 

the  plantar  flexion,  with  a  rather  sharp  break  in  the  resistance 
offered  to  the  spring  balance.  All  measurements  of  degrees  are 
made  to  the  plane  of  the  table  unless  otherwise  specified.  The  oper- 
ator guides  the  position  of  the  foot,  stimulates  the  patient  to  inner- 
vation, and  calls  the  moment  of  the  break  in  the  muscle  to  the 
assistant  for  reading  or  reads  the  scale  himself.  The  reading  of 
the  scale  must  be  simultaneous  with  this  break. 

"  Hip  Extension. — The  subject  lies  on  the  side  opposite  to  that  to 
be  tested,  with  the  hips  directly  one  above  the  other.  The  abdomen 
is  braced  against  the  hip  clamp  used  in  abduction  and  adduction. 
At  the  lower  end  of  the  table  two  C  clamps,  across  which  a 
small  board  is  placed  for  comfort,  are  used  by  the  patient  for  a 
brace.  He  pushes  against  this  with  the  foot  of  the  leg  not  being 
tested  to  secure  more  steadiness.  The  trunk  is  braced  forward 
by  the  patient  by  holding  to  the  edge  of  the  table  with  the  hands. 
The  operator  maintains  the  position  of  the  abdomen  against  the 
hip-brace  with  one  hand  and  with  the  other  supports  the  weight 
of  the  leg  to  be  tested,  and  keeps  the  leg  parallel  to  the  table. 
The  loop  is  at  the  knee  across  the  popliteal  space.  The  leg  is  placed 
in  maximum  extension  with  the  knee  straight.  The  direction  of 
pull  of  the  balance  is  slightly  less  than  90  degrees  to  the  leg,  being 
deflected  toward  the  trunk,  and  is  exerted  horizontally.  The  angle 
of  the  pull  must  be  constant  throughout  the  movement.  The 
operator  calls  for  the  reading  as  the  leg  crosses  the  line  of  the 
trunk,  or  if  the  muscle  gives  before  this,  the  reading  is  taken  when 
the  muscle  yields. 

"  Hip  Flexion.— The  side  position  and  hip  brace,  as  in  hip  exten- 
sion, are  used.  The  small  of  the  back  is  against  the  hip  brace. 
The  patient  maintains  the  rigidity  of  the  trunk  by  pushing  with 
the  hands  against  the  opposite  hip  brace.  The  operator  supports 
the  leg  parallel  to  the  table,  with  one  hand  at  the  knee  and  the 
other  at  the  ankle.  The  knee  is  well  bent  and  the  thigh  is  flexed 
above  the  right  angle.  The  pull  is  horizontal  and  as  near  as  possible 
at  right  angles  to  the  femur.  The  reading  is  taken  when  the  muscle 
gives. 

"Forearm  Extension. — The  patient  lies  on  the  back,  with  the 
arm  at  the  side,  and  the  forearm  perpendicular  to  the  table,  against 
which  the  elbow  rests.  The  hand  is  closed  with  the  thumb  point- 
ing to  the  shoulder.  The  loop  is  at  the  wrist  just  proximal  to  the 
styloid  process  of  the  ulna.  The  assistant  stands  at  the  head  of 
the  table  and  braces  with  one  hand  the  shoulder  of  the  side  to  be 


252     EXAMINATION  OF  MUSCLES  AND  MUSCLE  TRAINING 

tested.  The  operator  braces  the  elbow  on  the  table  with  one  hand, 
and  with  the  other  at  the  wrist  limits  the  extension  of  the  forearm. 
The  pull  is  horizontal.  At  the  direction  of  the  operator  the  exten- 
sion of  the  forearm  and  the  pull  of  the  assistant  start  together 
slowly.  Extension  is  permitted  to  from  5  to  15  degrees  from  the 
perpendicular  and  is  overcome  by  the  assistant.  The  call  for 
reading  of  the  scale  is  made  just  as  the  forearm  crosses  the  vertical 
line." 


CHAPTER    XVI. 

THE  PREVENTION  OF  THE  DISEASE. 

During  an  epidemic  physicians  are  constantly  asked  how  the 
disease  can  be  prevented  and  if  there  is  anything  that  can  be  done 
to  ward  it  off.  First,  let  us  consider  the  child  itself.  If  the  child 
has  not  been  definitely  exposed  to  the  disease  the  best  thing  to  do  is 
to  keep  it  in  the  best  possible  physical  condition  and  follow  out 
suggestions  given  in  the  circulars  of  information  for  the  public 
published  by  the  New  York  City  Health  Department,  which  are 
given  later  on.  There  have  been  numerous  suggestions  made  for 
protecting  the  child  by  the  use  of  antiseptics  in  the  nose  and 
throat.  All  sorts  of  solutions  have  been  recommended,  such 
as  5  or  10  per  cent,  argyrol,  10  per  cent,  colloidal  silver,  and 
the  various  well-known  alkalines  and  acid  antiseptic  solutions. 
The  nasal  mucous  membrane  produces  watery  soluble  protective 
substances  that  have  recently  been  actually  demonstrated.  In 
all  probability  the  use  of  various  antiseptic  agents  destroys 
this  and  so  robs  the  body  of  a  valuable  aid  in  warding  off  the 
disease.  It  is  perfectly  certain  that  the  prolonged  use  of  anti- 
septic solutions  in  the  nose  produces  irritation  of  the  mucous  mem- 
brane and  often  actual  pathological  processes.  Under  normal 
conditions  the  nose  will  look  after  itself.  It  has  also  been  shown  by 
experiment  that  the  use  of  the  ordinary  antiseptic  solutions  in  the 
nose  will  not  prevent  the  experimental  disease  in  monkeys.  Except 
as  stated  below  we  are  of  the  opinion  that  the  various  measures 
used  in  the  nose  and  throat  do  more  harm  than  good.  We  therefore 
advise  that  in  the  presence  of  an  epidemic  that  no  antiseptic  or  irri- 
tating solutions  be  used  in  the  nose  or  throat.  If  a  person  has  been 
definitely  exposed  to  the  disease,  such  as  a  nurse,  and  it  is  a  question 
of  whether  she  should  be  allowed  to  come  in  contact  with  the  child, 
we  advise  the  use  of  a  freshly  prepared,  10  per  cent,  argyrol  solution, 
five  drops  in  each  side  of  the  nose  while  the  patient  is  in  a  recumbent 
position,  so  that  it  covers  the  nasopharynx  completely,  and  this 
amount  is  instilled  three  or  four  times  a  day  for  two  or  three  days 
and  then  stopped.     Whether  this  is  a  proper  procedure  or  not  will 


254  THE  PREVENTION  OF   THE  DISEASE 

have  to  he  determined  hy  future  observations,  but  we  have,  at  least, 
had  no  instance  of  poUomyeHtis  developing  in  children  where  a 
nurse  or  parent  who  had  been  exposed  to  the  disease  has  used  this 
as  a  precautionary  measure.  Where  the  child  itself  has  been 
definitely  exposed  to  the  disease,  we  have  adopted  the  same 
procedure. 

A  modification  of  the  Dakin  solution,  so  that  it  may  be  used  on 
the  mucous  membrane  without  causing  irritation  will  probably 
be  found  to  be  what  is  most  efficient. 

Flexner  and  Clark^  have  carried  on  a  series  of  experimental 
poliomyelitis  in  monkeys  and  found  that  if  the  monkeys  are  given 
hexamethylenamin  before  the  virus  of  poliomyelitis  is  injected  into 
the  brain,  and  if  the  drug  is  administered  by  mouth  daily  after  the 
injection,  a  certain  proportion  of  the  animals  so  treated,  but  not 
all,  will  show  a  prolongation  of  the  incubation  period  (from  six  to 
eight  to  twenty-four  days)  and  the  onset  of  paralysis  may  be  entirely 
prevented.  Efforts  to  find  a  new  compound  starting  with  hexa- 
methylenamin that  will  exert  even  a  greater  action  in  this  regard 
up  to  the  present  time  have  not  been  successful.  We  see  no  objection 
and  possibly  good,  in  using  hexamethylenamin  in  children  who  have 
been  definitely  exposed  to  the  disease,  giving  from  1  to  5  grains  at  a 
dose  according  to  the  age,  and  giving  four  or  five  doses  a  day.  The 
drug  should  be  given  in  plenty  of  water,  and  we  generally  continue 
its  administration  from  one  to  two  weeks  after  the  exposure.  If 
the  child  develops  any  signs  of  irritation  of  the  urinary  tract  the 
drug  should  be  immediately  discontinued.  We  do  not  recommend 
the  indiscriminate  use  of  this  drug  in  individuals  who  have  not  been 
definitely  exposed. 

In  the  case  of  individuals  who  may  be  carriers,  such  as  nurses  and 
others  who  have  been  exposed  to  the  disease,  we  suggest  the  use  of 
10  per  cent,  argyrol  in  the  nose  for  two  or  three  days,  and  such 
individuals,  as  far  as  possible,  should  be  kept  away  from  young 
children  for  about  eight  days.  The  prevention  of  a  disease  like 
poliomyelitis,  where  the  exact  method  of  transmission  has  not, 
as  yet,  been  definitely  proved,  must  include  taking  the  various 
measures  that  cover  all  the  possibilities.  These  have  been  very 
well  summarized  in  circulars  issued  by  the  New  York  City  Depart- 
ment of  Health,  and  we  do  not  believe  that  we  can  do  better  than 
reprint  the  prophylactic  measures  as  they  have  published  them. 

1  Jour.  Am.  Med.  Assn.,  February  25,  1911,  p.  585. 


ISOLATION  OR  QUARANTINE  255 

The  following  suggestions  for  the  prevention  of  the  disease  have 
been  arrangefl  from  the  report  of  the  Conference  of  State  and 
Provincial  Boards  of  Health  of  North  America,  held  at  Washington, 
D.  C,  May  2  and  3,  1917,^  from  the  regulations  and  procedures  of 
the  Department  of  Health  of  the  City  of  New  York-  and  some  of  the 
pamphlets  issued  by  the  Department  of  Health  of  the  Citv  of  New 
York  during  the  epidemic  of  1916.  Some  of  the  paragraphs  have 
been  used  without  any  change  whatever. 

The  Incubation  Period. — For  purposes  of  quarantine  the  incubation 
period  of  the  disease  may  be  regarded  as  within  two  weeks  after 
exposure.  This  is  important  in  considering  the  length  of  time  to 
quarantine  people  who  have  been  in  contact  with  the  disease. 

Isolation  or  Quarantine. — During  the  epidemic  of  1916  a  quarantine 
period  was  first  used  of  eight  weeks.  This  was  shortened  to  six  and, 
in  some  instances,  to  four  weeks.  This  long  period  of  quarantine, 
if  it  is  not  necessary,  imposes  a  needless  expense  and  hardship  and 
leads  to  the  hiding  of  cases  and  mitil  it  has  been  very  definitely 
established  that  this  long  period  is  important,  we  would  suggest  the 
shorter  period  of  two  or  three  weeks  be  tried.  \Ye  are  inclined  to 
believe  that  for  the  average  case  this  will  be  shown  to  be  sufficient 
unless  the  fever  persists  or  there  is  discharge  from  the  nose  and 
throat,  neither  of  which  is  common  after  that  length  of  time. 

The  reasons  for  believing  that  this  shorter  period  will  be  sufficient 
are:  (1)  the  numerous  instances  in  ^\hich  the  diagnosis  is  not  made 
until  late,  so  that  the  patient  is  not  isolated  for  several  weeks  after 
the  date  of  onset,  and  yet  no  apparent  secondary  cases  appear;  (2) 
the  fact  that  the  longest  period  observed  in  which  a  primary  case 
was  the  source  of  infection  was  only  ten  days;  (3)  that  the  epidemio- 
logical experience  for  past  epidemics  does  not  seem  to  justify  a  long 
period  of  isolation;  (4)  the  fact  that  at  least  one  city  and  one  wState 
have  been  using  a  two  weeks'  period  of  isolation  for  all  knoAMi  cases 
of  poliomyelitis  for  several  years. 

The  patient  with  the  disease  should  be  isolated  for  the  period 
determined  upon,  that  is,  not  less  than  two  weeks  nor  ordinarily  over 
three  weeks  from  the  date  of  onset  of  the  disease  as  determined  by 
the  health  authorities,  and  not  from  the  date  of  the  diagnosis  or 
the  reporting  of  the  disease. 

Children  under  sixteen  years  of  age  (except  those  who  have  had 

1  Public  Health  Reports,  May  IS,  1917. 

2  Weekly  Bulletin  of  the  Department  of  Health  of  the  City  of  New  York,  June 
16,  1917. 


256  THE  PREVENTION  OF   THE  DISEASE 

the  disease)  who  remain  at  home  in  families  in  which  poliomyelitis 
has  occurred,  shall  be  quarantined  in  the  home  until  two  weeks 
after  the  termination  of  the  case  by  death,  removal,  or  recovery. 

Adults  of  the  household,  if  the  patient  is  isolated  at  home,  may 
continue  their  vocations,  provided  this  does  not  bring  them  into 
contact  with  children  under  sixteen  years  of  age,  and  provided  they 
are  not  engaged  in  the  preparation  and  handling  of  foods. 

Adults  excluded  from  their  usual  occupations  and  children  under 
sixteen  years  of  age  affected  by  the  preceding  regulations,  provided 
they  remove  to,  and  remain  at,  a  different  place  of  residence  and  are 
well  at  the  expiration  of  two  weeks  from  the  date  of  their  last 
contact  with  the  patient,  may  resume  their  usual  occupations. 

Placards. — All  premises  where  a  case  of  poliomyelitis  occurs 
should  be  placarded  (the  only  exceptions  being  hotels  and  boarding 
houses,  provided  the  patient  is  at  once  removed  to  a  hospital  and  the 
room  or  rooms  immediately  disinfected  and  provided  no  quarantined 
children  remain  on  the  premises).  In  private  houses  and  in  two- 
family  houses  with  separate  entrances  a  placard  should  be  placed 
on  the  door  entering  the  room  the  patient  occupies.  In  apartment 
and  tenement  houses  a  placard  should  be  posted  on  the  door  of  the 
apartment  occupied  by  the  family  of  the  patient.  In  two-family 
houses  with  a  common  entrance  one  placard  shall  be  placed  on 
the  door  entering  the  portion  occupied  by  the  family  of  the  patient 
and  one  upon  the  room  or  rooms  occupied  by  the  patient. 

Removal  to  Hospital. — No  patient  should  be  left  at  home  unless 
the  following  conditions  are  complied  with  to  the  satisfaction  of  the 
Health  Department,  providing  the  Health  Department  has  adequate 
hospital  facilities  for  caring  for  the  cases: 

(a)  There  must  be  a  physician  in  frequent  attendance. 

(6)  The  patient  must  have  a  special  attendant,  who  must  obey 
quarantine  regulations  and  must  not  do  any  housework,  marketing, 
or  perform  any  household  duties  for  other  members  of  the  family. 
The  attendant  may,  however,  leave  the  house,  provided  the  neces- 
sary precautions  as  to  personal  disinfection  are  observed,  but  all 
children  must  be  avoided. 

(c)  The  patient  and  the  attendant  must  have  a  room,  or  rooms; 
separate  from  the  rooms  of  others  in  the  family. 

(d)  All  the  windows  of  this  room  must  be  screened  and  all  flies 
in  the  room  killed. 

(e)  The  family  must  have  a  separate  toilet  for  its  exclusive  use. 
(/)  Isolation  and  quarantine  regulations  must  be  strictly  observed 

by  the  patient  and  other  children  of  the  family. 


HEALTH  DEPARTMENT  NURSES  257 

(g)  All  discharges  from  the  nose,  throat,  and  bowels  of  the 
patients  and  all  articles  soiled  therewith  shall  be  promptly  disin- 
fected, and  attendants  shall  wash  their  hands  with  soap  and  hot 
water  promptly  after  handling  such  discharges  or  articles. 

Attendants  shall,  in  the  same  manner,  wash  their  hands  and 
change  their  clothing  before  leaving  the  room  occupied  by  the 
patient. 

All  eating  utensils  and  personal  and  bed-clothing  shall  be  properly 
disinfected. 

Requirements  for  Nurses  and  Physicians. — The  nurse  in  attendance 
should  wear  a  cap  and  gown  over  her  ordinary  clothes,  which  should 
all  be  of  wash  material,  and  this  may  be  supplemented  by  the  use 
of  a  gauze  nose  and  mouth  protector  such  as  are  used  in  infectious 
disease  hospitals.  This  latter  procedure  was  dispensed  with  in  some 
of  the  hospitals  during  the  epidemic  of  1916,  without  any  apparent 
spread  of  the  disease  by  the  individuals  who  were  not  so  protected 
from  becoming  carriers,  and,  no  doubt,  its  use  should  not  be  made 
obligatory.  The  physician  should  wear  a  gown  which  may  be 
supplemented  with  a  cap  and  mouth-piece,  or  not,  and  both  physi- 
cian and  nurse  should  avoid  contact  with  the  patient  as  far  as  pos- 
sible, and  also  to  use  every  precaution  to  avoid  being  soiled  by  dis- 
charges and  by  droplet  infection  from  the  patient.  On  the  first 
visit,  if  the  physician  does  not  have  a  gown,  care  should  be  taken 
not  to  allow  the  clothes  to  come  in  contact  with  the  patient  or 
bedding. 

Before  leaving,  both  the  physician  and  nurse  should  scrub  their 
hands  thoroughly  with  soap  and  hot  water. 

The  nurse  in  attendance  on  a  case  of  poliomyelitis  need  not  be 
isolated  during  the  whole  period,  providing  she  changes  her  clothes 
when  she  goes  out  and  avoids  coming  in  contact  with  children  and 
frequenting  crowded  places  as  far  as  possible. 

Terminal  Disinfection  or  Renovation. — After  removal,  recovery, 
or  death  of  the  patient,  disinfection  or  complete  renovation  of  the 
room  or  rooms  occupied  by  the  patient  and  attendant  is  required, 
and  after  recovery  of  the  patient,  isolation  shall  be  terminated  by  a 
thorough  washing  of  the  entire  body  and  hair  of  the  patient. 

Health  Department  Nurses. — Nurses  should  visit  every  case 
reported,  to  instruct  the  family  regarding  isolation  of  the  patient 
and  quarantine.  Every ^other  family  in  the  house^should  be  warned 
by  her  as  follows: 

(a)  That  there  is  a  case  of  the  disease  in  the  house. 
17 


258  THE  PREVENTION  OF   THE  DISEASE 

(6)  That  the  other  children  of  the  family  in  which  the  disease 
has  occurred  will  be  quarantined,  and,  should  they  fail  to  observe 
quarantine,  that  fact  should  be  immediately  reported  to  the  Depart- 
ment of  Health,  in  order  that  steps  may  be  taken  to  enforce  it. 

(c)  Regarding  home  cleanliness,  personal  hygiene,  the  danger 
of  infection  by  flies,  and  other  general  measures  which  should  be 
taken  to  prevent  infection. 

(d)  To  report  at  once  to  the  department  any  cases  of  suspicious 
illness  of  children,  or  any  cases  of  poliomyelitis,  especially  if  there 
is  no  physician  in  attendance. 

Visits  of  Parents  or  Guardians  to  Hospital  Cases.^ — The  New  York 
Health  Department  allows  each  case  to  be  visited  twice  during  its 
stay  in  the  hospital  by  a  parent  or  guardian.  If  the  child  is  critically 
ill  the  parent  or  guardian  is  notified  and  is  permitted  to  visit  daily 
while  the  child  is  dangerously  ill. 

When  parents  or  guardians  are  admitted  to  the  wards  they 
should  be  gowned  the  same  as  the  nurse  and  use  the  same  precautions 
on  leaving. 

Return  of  Poliomyelitis  Patients. — In  cases  where  poliomyelitis 
occurs  in  residents  of  a  town  who  are  temporarily  residing  outside 
of  it,  if  the  disease  develops  within  two  weeks  of  the  time  of  leaving 
the  town  the  patient  should  be  permitted  to  return,  provided  that 
it  is  brought  in  a  private  conveyance,  that  is,  a  private  car,  private 
automobile,  carriage  or  ambulance,  and  also  that  the  patient  goes 
direct  to  a  hospital  which  is  prepared  to  care  for  such  cases. 

Where  the  case  is  developed  after  two  weeks,  it  would  seem  more 
logical  to  make  thecommunity  in  which  the  disease  develops  care  for  it. 

Return  of  Children  Who  have  been  Exposed  to  Poliomyelitis. — 
Children  under  sixteen  years  of  age  temporarily  outside  of  the 
community  in  which  they  usually  reside,  who  have  been  exposed 
to  infection  of  poliomyelitis  within  two  weeks,  should  be  allowed  to 
return,  provided  they  come  by  private  conveyance  and  go  directly 
to  their  homes.  Advance  notice  of  their  coming  should  be  sent  to 
the  local  health  authorities  and  permission  obtained  from  them, 
if  necessary,  by  telephone. 

Such  children  should  be  visited  by  the  nurse  or  inspector  of  the 
Department  of  Health  and  they  should  be  kept  in  quarantine  until 
two  weeks  have  elapsed  from  the  date  of  the  last  exposure. 

It  is  not  necessary  to  placard  the  premises  in  these  cases,  but  the 
children  should  be  visited  at  regular  intervals  to  see  whether  the 
quarantine  is  being  broken. 


NURSE  259 

Care  of  the  Patient  and  Surroundings. — Complete  isolation  of  the 
patient  must  be  maintained  until  terminated  by  order  of  the  Depart- 
ment of  Health. 

A  separate  room  must  be  provided  for  the  patient.  Xo  one  musi 
be  allowed  in  this  room  except  the  attending  physician,  the  nurse 
and  the  representative  of  the  Department  of  Health. 

(a)  All  rugs,  carpets,  draperies  and  unnecessary  furniture  must 
be  removed  before  the  patient  is  placed  in  the  room,  (h)  All 
windows  must  be  screened  or  mosquito-netting  placed  over  the  bed 
so  as  to  protect  the  patient  from  flies  or  other  flying  insects,  (c) 
The  sick  room  must  be  kept  well  aired  at  all  times,  (c?)  The  wood- 
work must  be  wiped  with  damp  cloths  daily.  Under  no  circum- 
stances must  the  floor  be  swept  when  i1  is  dry.  It  should  be  sprinkled 
with  sawdust,  bits  of  newspaper,  or  tea  leaves,  all  thoroughly 
moistened,  and  then  carefully  swept  so  thai  no  dust  may  arise. 
(e)  Toys  and  books  used  by  the  patient  must  be  destroyed  by 
burning  after  recovery  or  death.  (/)  Household  pets  must  not  be 
allowed  in  the  room. 

Care  of  Bedding. — All  cloths,  bed-linen,  and  personal  clothing 
which  have  come  in  contact  in  any  way  with  the  patient  must 
immediately  be  immersed  in  a  5  per  cent,  solution  of  carbolic  acid 
and  allowed  to  soak  for  three  hours.  They  may  then  be  removed 
from  the  room  and  must  be  boiled  in  water  or  soapsuds  for  fifteen 
minutes. 

Care  of  Discharges  from  the  Body. — A  sufficient  supply  of  gauze  or 
clean  linen  or  cotton  cloth  must  be  provided,  and  all  discharges 
from  the  nose  and  mouth  of  the  patient  received  on  these  cloths. 
After  use  they  must  be  immediately  burned. 

Bowel  discharges  and  urine  must  be  covered  at  once  with  chloride 
of  lime  and  then  be  disposed  of  by  emptying  into  a  water-closet. 

Care  of  Utensils  Used  by  Patient. — Plates,  glasses,  cups,  knives, 
forks,  spoons,  and  other  utensils  used  by  the  patient  must  be  kept 
for  his  exclusive  use,  and  under  no  circumstances  removed  from  the 
room  or  mixed  with  similar  utensils  used  by  others.  They  must  be 
washed  in  the  room  in  hot  soapsuds  and  then  rinsed  in  boiling  water. 
After  use  the  soapsuds  and  water  must  be  throAm  into  the  water- 
closet. 

Nurse. — A  trained  nurse  or  competent  attendant  must  be  in  sole 
attendance  upon  the  patient.  She  must  not  be  allowed  to  mingle 
with  the  rest  of  the  famih',  but  must  be  isolated  with  the  patient. 
The  hands  of  the  nurse  must  be  carefully  washed  in  hot  soapsuds 
after  each  contact  with  the  patient  and  before  eating. 


260  THE  PREVENTION  OF  THE  DISEASE 

Termination  of  Case. — After  each  case  has  been  ordered  terminated 
by  the  Department  of  Health  the  following  procedure  must  be 
followed :  (a)  The  entire  body  of  the  patient  must  be  washed  and 
the  hair  washed  with  hot  soapsuds.  The  patient  should  then  be 
dressed  in  clean  clothes  (which  have  not  been  in  the  sick  room  during 
the  illness)  and  removed  from  the  room.  (6)  The  nurse  should 
also  take  a  bath,  wash  her  hair,  and  put  on  clean  clothes  before 
mingling  with  the  family  or  other  people. 

General  Suggestions. — Children  living  in  a  house  where  there  is  a 
case  of  the  disease  should  be  allowed  out  of  doors,  but  should  be 
kept  by  themselves.  If  there  is  a  yard  or  roof  in  which  they  can 
play  they  should  not  be  allowed  outside  of  it  for  at  least  two  weeks 
after  they  have  been  exposed  to  the  disease. 

Fresh-air  outing  or  vacation  camps  are  permissible,  if  kept  under 
competent  medical  supervision  and  care  is  taken  to  exclude  any 
child  from  an  infected  family. 

Where  the  disease  occurs  in  a  school  it  need  not  be  closed,  but 
the  children  should  be  inspected  daily  by  some  medical  officer. 

Absolute  cleanliness  of  all  homes  is  essential  whether  there  are 
cases  in  them  or  not;  such  cleanliness  should  include:  (a)  screens 
in  all  windows;  (6)  flies  kept  out  of  all  rooms;  (c)  thorough  cleanli- 
ness of  all  floors,  woodwork,  bedding,  and  clothing;  (d)  avoidance 
of  dust  (all  sweeping  should  be  done  after  the  floors  have  been 
sprinkled  with  sawdust,  bits  of  newspaper  or  tea  leaves,  all  thor- 
oughly moistened ;  (e)  garbage  can  kept  covered  and  washed  out  in 
hot  soapsuds  after  they  have  been  emptied;  (/)  no  refuse,  either 
of  food  or  other  waste,  allowed  to  accumulate. 

Travel. — As  far  as  possible,  traveling  during  an  epidemic  should 
be  discouraged,  particularly  for  children  under  sixteen  years  of  age. 
The  only  people  who  need  watching  are  those  who  have  definitely 
come  in  contact  with  the  disease  and  where  they  are  known  it  is 
best  to  keep  them  under  observation.  The  use  of  travel  certificates 
and  any  attempt  to  inspect  or  supervise  travelers  are  certainly 
useless. 

Information  for  the  Public  Published  by  the  New  York 
City  Department  of  Health. 

(From  a  circular  issued  by  the  Department  of  Health  of  the 
City  of  New  York.) 
Infantile  paralysis  (poliomyelitis)  is  a  catching  disease.    How  it  is 


HOW  TO  GUARD  AGAINST  THE  DISEASE  2G1 

spread  is  not  yet  definitely  known.  In  most  cases  the  disease  is 
probably  taken  directly  from  a  sick  person,  but  it  may  be  spread 
indirectly  through  a  third  person  who  has  been  taking  care  of  the 
patient,  or  children  who  have  been  living  in  the  same  household. 

The  early  symptoms  are  usually  fever,  weakness,  fretfulness  or 
irritability,  and  vomiting.  There  may  or  may  not  be  acute  pain 
at  this  time.  Later,  there  is  pain  in  the  neck,  back,  arms  or  legs, 
with  great  weakness.  If  paralysis  is  to  occur  it  usually  appears  from 
the  second  to  the  fifth  day  after  the  sickness  begins.  Many  cases 
do  not  go  on  to  paralysis. 

The  germ  of  the  disease  is  present  in  the  discharges  from  the  nose, 
throat,  and  bowels  of  those  ill  with  infantile  paralysis,  even  in  the 
cases  that  do  not  go  on  to  paralysis.  It  may  also  be  present  in  the 
nose  and  throat  of  healthy  children  from  the  same  family.  Do  not 
let  your  children  play  with  children  who  have  just  been  sick  or  who 
have  or  recently  have  had  colds,  summer  complaint,  etc.  For  this 
reason  children  from  a  family  in  w^hich  there  is  a  case  of  infantile 
paralysis  are  forbidden  to  leave  their  home.  If  you  hear  of  their 
doing  so,  report  it  at  once  to  the  Department  of  Health. 

Persons  over  sixteen  years  of  age,  from  families  in  which  there  are 
cases  of  poliomyelitis,  may  continue  at  work  unless  their  business 
has  to  do  with  the  preparation  or  handling  of  food  or  drink  for  sale. 

If  you  hear  of  a  case  in  your  neighborhood  and  the  house  is  not 
placarded,  notify  the  Department  of  Health. 

How  to  Guard  against  the  Disease. 

In  order  to  prevent  the  occurrence  of  this  disease,  parents  should 
observe  the  following  rules: 

Keep  your  house  or  apartment  absolutely  clean. 

Go  over  all  woodwork  daily  with  a  damp  cloth. 

Sweep  floors  only  after  they  have  been  sprinkled  with  sawdust, 
old  tea  leaves,  or  bits  of  newspaper  which  have  been  thoroughly 
dampened.     Never  allow  dry  sweeping. 

Screen  your  windows  against  flies,  and  kill  all  flies  in  the  house. 

Do  riot  allow  garbage  to  accumulate,  and  keep  pail  closely  covered. 

Do  not  allow  refuse  of  any  kind  to  remain  in  your  rooms. 

Kill  all  forms  of  vermin,  such  as  bed-bugs,  roaches,  and  body  lice. 

Pay  special  attention  to  bodily  cleanliness.  Give  the  children  a 
bath  every  day  and  see  that  all  clothing  which  comes  into  contact 
with  the  skin  is  clean. 


262  THE  PREVENTION  OF  THE  DISEASE 

Keep  your  children  by  themselves  as  much  as  possible.  Do 
not  allow  them  to  visit  moving-picture  shows  or  other  places  in  which 
children  may  gather. 

Children  should  not  be  kept  in  the  house;  they  should  be  outdoors 
as  much  as  possible,  but  not  in  active  contact  with  other  children 
in  the  neighborhood.  Do  not  take  them  on  a  street  car  unless 
absolutely  necessary,  or  shopping. 

Do  not  allow  your  children  to  be  kissed. 

It  is  perfectly  safe  to  let  your  children  go  to  the  parks  and  play- 
grounds if  only  two  or  three  of  them  play  together;  they  should  not 
play  in  large  groups,  and  you  should  not  let  them  come  into  contact 
with  children  from  other  parts  of  the  city. 

Remember  that  children  need  fresh  air  in  the  summertime,  and 
outdoor  life  is  one  of  the  best  ways  to  avoid  disease. 

If  there  is  a  public  shower  bath  in  a  school  in  your  vicinity  send 
the  older  children  there  every  day  for  a  shower  bath.  This  is  per- 
fectly safe  and  will  help  keep  them  in  good  health. 

Give  your  children  plain,  wholesome  food,  including  plenty  of 
milk  and  vegetables. 

Keep  the  milk  clean,  covered,  and  cold. 

Do  not  allow  the  milk  or  any  other  food  to  be  exposed  where 
flies  may  alight  on  it. 

Wash  well  all  food  that  is  to  be  eaten  raw. 


In  Case  of  Sickness. 

Remember  that  during  the  hot  weather,  children  are  apt  to  have 
stomach  and  bowel  troubles.  If  your  child  is  taken  sick  with  loose 
movements  of  the  bowels,  or  with  vomiting,  do  not  at  once  fear 
that  it  must  be  infantile  paralysis;  it  may  be  simply  digestive 
disturbance.  Give  the  child  a  tablespoonful  of  castor  oil  and  plenty 
of  cool  water  to  drink,  and  send  for  a  doctor  at  once. 

If  you  cannot  afford  a  doctor's  services,  telephone  the  Depart- 
ment of  Health,  and  one  will  be  sent  free  of  charge. 

If  a  doctor  or  nurse  from  the  Department  of  Health  visits  your 
home,  give  them  all  the  information  you  can.  They  are  sent  to  show 
you  how  to  keep  your  children  well. 

Do  not  give  your  children  patent  medicines  or  buy  charms  of 
any  kind  to  ward  off  the  disease.  The  best  preventive  is  cleanliness 
and  strict  observance  of  the  rules  that  have  been  given. 

Although  there  is  no  specific  cure  for  the  disease,  much  can  be 


State  quarantine  2GS 

done  to  reduce  the  amount  of  crippling  caused  by  the  paralysis.  It 
is  important  to  remember  that  this  requires  the  services  of  a  trained 
physician  and  the  care  of  a  competent  nurse.  Unless  }'ou  can  give 
these  to  your  child,  send  word  at  once  to  the  Department  of  Health, 
so  that  the  patient  may  receive  proper  care  in  a  well-equipped  hos- 
pital. Of  the  children  cared  for  in  hospitals,  only  one-fourth  as  many 
died  as  of  those  treated  at  home.  Give  your  child  a  fair  chance  and 
let  the  hospital  doctors  care  for  it. 

What  the   Health    Department  Will   Do. 

If  a  case  of  infantile  paralysis  occurs  in  your  home,  your  doctor 
must  at  once  notify  the  Department  of  Health.  An  inspector  will 
be  sent  to  investigate.  He  will  paste  a  sign  on  the  door  of  your 
apartment,  warning  all  people  not  to  enter.  This  sign  must  not  be 
removed  except  by  someone  sent  by  the  Department  of  Health. 
The  inspector  and  nurse  will  tell  you  just  what  to  do  to  protect 
yourself  and  the  others  in  the  family. 

State  Quarantine. — A  word  on  this  subject  may  not  be  amiss, 
inasmuch  as  the  northern  part  of  the  United  States  in  the  late  sum- 
mer and  fall  of  1916  was  treated  to  a  governmental  vaudeville  in 
the  guise  of  interstate  and  intercity  quarantine.  Some  years  ago, 
in  the  South,  this  shotgun  method  was  frequently  used  in  connec- 
tion with  the  miscontrol  of  yellow  fever.  With  the  discovery  of 
the  method  of  transference  of  the  yellow-fever  virus  this  form  of 
barbarism  happily  passed  away.  Unfortunately  it  was  revived  in 
1916,  first  one  State  quarantining  against  the  other  until  all  of  the 
group  of  States  were  quarantined  against  each  other.  An  efl'ort 
was  made  to  inspect  travelers  and  supply  them  with  cards,  but 
there  was  little  or  no  investigation  of  the  person  to  whom  the  card 
was  issued.  There  was  a  vast  amount  of  regulation  and  large 
forces  of  Federal,  State  and  municipal  officials  joined  in  wasting 
people's  time,  money,  and  patience,  with  the  result  that  the  disease 
pursued  the  course  which  might  have  been  anticipated  had  nothing 
whatever  been  done. 

State  quarantine  measures,  in  fact  all  others,  should  deal  with 
the  sick  individual  and  those  who  have  been  exposed  to  the  disease. 
Any  further  supervision  will  have  to  be  carried  out  in  a  manner 
which  will  not  have  any  material  effect  on  the  spread  of  the  dis- 
ease, and  which  will  undoubtedly  weaken  the  faith  of  the  people 
in  the  wisdom  of  health  authorities. 


CHAPTER    XVIl. 

BIBLIOGRAPHY. 

We  have  not  included  any  special  list  of  references  beyond  those 
given  in  the  text,  as  the  class  of  writers  for  whom  this  book  was 
intended  will,  for  the  most  part,  be  either  out  of  reach  of  medical 
libraries  of  sufficient  size  or  will  lack  sufficient  time  to  make  the 
necessary  researches.  Those  particularly  interested  will  find  a 
very  full  list  of  references  in  the  Index  Catalogue  of  the  Library  of 
the  Svrgeon-GeneraVs  Office,  United  States  Army.  In  the  first  series 
the  list  is  in  vol,  x,  1889,  p.  438  et  seq.,  and  in  the  second  series 
in  vol.  xiii,  1908,  p.  610  et  seq.  Other  references  to  the  current 
literature  will,  of  course,  be  found  in  the  Index  Medicus.  The 
reports  of  greatest  interest  are  those  of  Wickman,  republished  in 
1913  in  New  York,  as  No.  6  of  the  Nervous  and  Mental  Diseases 
Monograph  Series;  the  report  of  the  New  York  epidemic  of  1907; 
The  Investigations  on  Epidemic  Infantile  Paralysis,  by  Kling, 
Wernstedt  and  Pettersson,  printed  in  English  for  the  Fifteenth 
International  Congress  on  Hygiene  and  Demography,  Washington, 
1912,  and  to  be  obtained  through  the  Nordiska  Bokhandeln,  Stock- 
holm. The  most  important  contribution  is  the  clinical  study  by 
Peabody,  Draper  and  Dochez,  which  is  vol.  iv  of  the  monographs 
for  the  Rockefeller  Institute  for  Medical  Research,  published  in 
New  York  in  1912.  The  epidemiology  is  given  by  Frost  in  Bulle- 
tin 90  of  the  Hygienic  Laboratory,  United  States  Public  Health 
Service,  1912;  and  the  treatment  in  a  little  work  entitled  The  Treat- 
ment of  Infantile  Paralysis,  by  Robert  W.  Lovett,  of  Boston,  pub- 
lished in  Philadelphia  in  1916.  The  surgical  treatment  is  given  in 
detail  in  the  book  of  Oskar  Vulpius,  1910,  translated  in  1912  by 
Todd.  Other  articles  of  interest  are  those  by  Seeligmiiller,  in 
Gerhardt's  Handbuch  der  Kinderkrankheiten,  vol.  v,  part  i,  1880; 
by  Mary  Putnam  Jacobi,  in  Pepper's  System  of  Medicine,  vol.  v, 
1886;  by  Wharton  Sinkler,  in  Keating's  Cyclopedia  of  the  Diseases 
of  Children,  vol.  iv,  1891.  The  most  recent  publications  are  the 
monographs  on  the  Epidemic  of  1916,  by  the  New  York  Health 
Department,  and  on  the  Acute  Stages,  by  Draper. 


CHAPTER    XVIII. 
SOME  ANATOMICAL  AND  PHYSIOLOGICAL  REMINDERS. 

Those  of  us  in  active  practice  find  it  difficult  to  keep  in  mind  the 
various  anatomical  facts  which  were  so  familiar  in  student  days, 
and  for  that  reason  we  are  appending  a  few  of  the  well-known  tables 
and  plates  to  serve  as  reminders  in  the  study  of  cases  of  poliomyelitis, 
as  the  interest  in  paralytic  conditions  is  greatly  enhanced  by  a 
knowledge  of  just  what  tissues  are  involved.  The  older  writers 
differentiated  the  white  part  from  the  gray  matter  of  the  nervous 
system,  and  later  found  out  that  the  white  part  was  made  up  of 
fibers  and  the  gray  of  cells.  More  recently  the  interrelation  of  the 
cells  and  fibers  has  been  more  clearly  determined,  and  the  idea  of 
neurons  has  become  all-important  in  the  consideration  of  disease 
of  the  nervous  system. 

The  upper,  or  corticospinal,  neuron  consists  of  the  tract,  including 
the  fibers  originating  in  the  cortex,  which  pass  down  through  the 
pyramidal  tracts  and  reach  the  nuclei  of  the  various  cranial  nerves 
in  the  crura,  pons,  and  medulla  and  thence  down  the  spinal  cord, 
where  fibers  run  to  the  anterior  horn  cells.  If  a  lesion  occurs  in  the 
upper  motor  neuron  the  fibers  involved  degenerate  at  once  below 
the  lesion.  This  degeneration  does  not  affect  the  lower  motor 
neuron.  This  takes  away  the  cortex  or  other  nerve-cell  control, 
and  results  in  a  motor  paralysis  without  wasting  of  the  muscles  and 
with  a  condition  of  spasticity.  The  deep  reflexes  are  exaggerated, 
and  if  the  leg  is  involved  the  plantar  reflex  is  extension.  The 
electrical  reaction  remains  normal.  The  lower,  or  spinomuscular, 
neuron  starts  from  the  anterior  horn  cells  and  passes  through  the 
peripheral  motor  nerves  to  the  muscles.  A  lesion  results  in  degenera- 
tion below  it  with  a  resulting  flaccid  motor  paralysis,  accompanied 
with  muscular  atrophy  and  absence  or  lessening  of  the  deep  reflexes. 
The  plantar  reflex,  if  it  can  be  elicited,  is  the  normal  flexion  unless 
the  flexor  muscles  themselves  are  paralyzed.  The  following  table 
from  Starr  shows  the  localization  of  the  muscular  reflex  acts  in  the 
cord : 


266    SOME  ANATOMICAL  AND  PHYSIOLOGICAL  REMINDERS 


Localization  of  Muscular  Reflex  Acts  in  the  Spinal  Cord, 


Reflex  acts. 

Pupillary  reflex  through  the  sympathetic  :  Dil- 
atation of  the  pupil  produced  by  irritation  of 
the  neck. 

Scapular  reflex  :  Irritation  of  the  skin  over  the 
scapula  produces  contraction  of  the  scapular 
muscles. 

Biceps  and  supinator  longus :  Tapping  their 
tendons  produces  flexion  of  the  forearm. 

Triceps  reflex  :  Tapping  tendon  produces  ex- 
tension of  forearm. 

Scapulohumeral  reflex  :  Tapping  the  inner  lower 
edge  of  the  scapula  causes  adduction  of  the 
arm. 

Tapping  extensor  tendons  at  the  wrist  causes  ex- 
tension of  the  hand. 
Tapping  flexor  tendons  at  the  wrist  causes  flexion 

of  the  hand. 
Palmar  reflex  :  Stroking  palm  causes  closure  of 

fingers ;  finger  clonus. 
Abdominal  reflex  :   Stroking  side  of  abdomen 

causes  retraction. 
Genital  reflex :   Squeezing  the   testicle   causes 

contraction  of  the  abdominal  muscles. 
Patella  tendon  :  Striking  tendon  at  knee  causes 

extension  of  the  leg  ;   "knee-jerk." 
Achilles  tendon  reflex  :   Tapping  the  Achilles 

tendon  causes  flexion  of  ankle. 
Foot  clonus :    Extension    of    Achilles   tendon 

causes  flexion  of  the  ankle. 
Plantar  reflex :   Tickling  sole   of  foot  causes 

flexion  of  the  toes. 
Babinski's  reflex  :  Scratching  sole  of  foot  causes 

extension  of    great  toe  and    flexion  of   the 

others. 
Mendel's  reflex :  Tapping  the  tendons  of  the 

toes  causes  flexion  or  extension  of  the  toes. 
Gordon's  reflex :  Deep  pressure  on  muscles  of 

calf  of  leg  causes  extension  of  the  toes. 
Oppenheim's  reflex  :  Stroking  the  outer  side  of 

the  leg  near  the  tibia  causes  retraction  of  the 

toes  and  contraction  of  the  tibialia  anticus. 
Snasm  of  anus  on  irritation. 


Localization  in  segment. 
Fourth  cervical  to  first  dorsal. 

Fifth  cervical  to  first  dorsal. 

Fifth  and  sixth  cervicaL 
Sixth  cervical. 
Seventh  cervical. 

Sixth  to  eighth  cervical. 
Seventh  to  eighth  cervical. 
Eighth  cervical  to  first  dorsal. 
Ninth  to  twelfth  dorsal. 
First  to  third  lumbar. 
Second  and  third  lumbar. 
First  to  third  sacral. 
First  to  third  sacral. 
First  to  third  sacral. 
First  to  third  sacral. 

First  to  third  sacral. 
First  to  third  sacral. 
First  to  third  sacral. 

Fourth  and  fifth  sacral. 


It  is  also  of  interest  to  know  the  location  of  the  segments  of  the 
cord  in  relation  to  the  vertebrae,  and  this  is  admirably  shown  in  the 
figure  from  Starr  on  page  268.  The  figure  from  Gray,  after  Jacob, 
on  page  269  shows  graphically  the  part  of  the  nervous  system  con- 
trolling the  various  muscle  reflexes  and  functions,  and  is  most  useful 
in  connection  with  the  preceding  illustrations. 

In  this  connection  the  level  of  the  cells  in  the  spinal  cord  is  of 
interest  and  is  well  shown  in  the  following  table  from  Starr: 


SOME  ANATOMICAL  AND  PHYSIOLOGICAL  REMINDERS   267 


Showing  the  Muscles  Represented  in  Groups  of  Cells  in 
THE  Various  Segments  of  the  Spinal  Cord. 


n.,  ni. 

IV. 

V. 

VL 

VIL 

VIIL 

I. 

Cervical. 

CervicaL 

Cervical. 

Cervical. 

CervicaL 

Cervical. 

DorsaL 

Diaphragm. 

Diaphragm. 

Sterno- 

Lev.  an  g.  soap. 

mastoid. 

Rhomboid. 

Rhomboid. 

Trapezius. 

Supra-  and 

Supra-  and 

Scalenus. 

infraspin. 
Deltoid. 
Supin.  long. 
Biceps. 

infraspin. 
Deltoid. 
Supin.  long. 
Biceps. 
Supin.  brev. 
Serratus  mag. 

Biceps. 

Serratus  mag. 

Pect.  (clav. ). 

Pect.  (clav.;. 

Teres  minor. 

Pronators. 
Triceps. 
Brach.  ant. 
Long  exten- 
sors of  wrist 

Pronators. 

Triceps. 

Brach.  ant. 

Long  exten- 
sors of  wrist 
and  fingers. 

Pect.  (costal). 

Latis.  dorsi 

Teres  major. 

Long  flexors 
of  wrist  and 
fingers. 

Long  flexors 

of  wrist  and 

fingers. 
Extensor  of 

thumb. 
Intrinsic 

muscles  of 

hands. 

Extensor  of 

thumb. 
Intrinsic 

muscles  of 

hands. 

I.    Lumbar. 

II.    Lumbar. 

IIL    Lumbar. 

IV.    Lumbar. 

V.    Lumbar. 

Quadr  lumb. 

Obliqui. 

Transversalis. 

Psoas 

Psoas. 

niacus. 

Iliacus. 
Sartorius. 
Quad.  ext.  cruris. 

Quad.  ext.  cruris. 

Obturator. 

Adductores. 

Obturator. 

Adductores. 

Glutei. 

Glutei. 

Biceps  femoris. 

Semi-tend. 

Popliteus. 

L    Sacral. 

n.    Sacral. 

III.    Sacral. 

IV.  and  V.  Sacral. 

Biceps  femor 
Semi-memb. 
Ext.  long.  dig. 
Gastroc. 
Tibialis  post 

Gastroc. 

Tibialis  post. 

Tibialis  anticus. 

Peronei. 

Intrinsic  muscles  of  foot 

Peronei. 

Intrinsic  muscles  of  foot 

Sphincter  ani  et  vesicae. 
Perineal  muscles. 

268    SOME  ANATOMICAL  AND  PHYSIOLOGICAL  REMINDERS 

The  relation  of  the  various  tracts  of  the  cord  are  of  importance, 
and  to  aid  in  the  differential  diagnosis  and  the  study  of  exceptional 


-^ 


N.  io  rectus  lateralif 

to  rectuB  antic*  minor 

Anaetomoais  vAth  hypogloeaal 

AnastomoRiB  with pneumogaairic 

iV.  to  rectus  antic,  major, 

N.to  mastoid  region . 

Great  auricular  n, 

Transverse  carvical  n . 

VirJiS   ^'  to  Trapezius,  Ang»  Scap.  and  R?tomboid. 

Svpra  clavicular  n, 

Su2tra-acromial  n . 

-Phrcnia  n. 

-^A.  to  Icvattyr  ang.  scap. 
-    N.  to  rhomboid 
-—Subscapular  n. 
Subclavicular  n. 


.  N.  to  peetoralis  major. 


Post,  thoraic 


Circumjlcx  «. 

__Mu8culo-mitaneou»  n. 

_Median  n, 

.Radial  n, 

_  Ulnar  n , 

_  Internal  cutaneous  n. 


■VU                 ' 

^VIU 

[^X7/ 

^   'l)^-^ 

|^P>^ 

>M Ilio-hgpogaetrie  n. 

l^^fV 

^\.._.2lio-inQuinal  w. 

^^^"V 

^\. internal  cutaneous  n 

/  U-^  IT^ 

X Genito-crv/ral «. 

y^^ST  ij 

V 

5w/ 

^     Anterior  crural  n. 

LS.ll/      /— 

Obturatorn. 

Superior  gluteal  n. 


A.  toUvatorani i^\ 

JV,  to  obturator  int.  — 
Ni  to  o2)hincter  ani.  — 
Coccygeal  n. 


.iV.  to  gemellus  infer, 
-N*  to  guadratus 
_  Small  sciatic  n. 
.. Sciatic  n. 


Fig.  112. — The  relations  of  the  segments  of  the  spinal  cord  and  their  nerve  roots  to 
the  bodies  and  spines  of  the  vertebrae.     (Starr.) 

cases  we  have  included  on  pages  270  and  271  the  figure  and  the 
explanatory  tables  from  Jelliffe  and  White: 


SOME  ANATOMICAL  AND  PHYSIOLOGICAL  REMINDERS   269 


LOCATION  OF  THE  SEGMENTS  FOR 

Sensibility.  Motility. 


Thoracic  and  abdominal 

Occipital  region 

Front  of  neck 

Back  of  neck 

Shoulder 

(Musculo- 
spiral  n. 
Median  n. 
Ulnar  n. 


Inferior  abdominal  reflex 

Gluteal  region 

Inguinal  region 

Hips 

C  -interior 

Thigh  I  Median 

1  External 

\_  Posterior 

j^i  Internal 

i  External 

Foot 

Scrotum,  penis,  etc.  — 

Bladder,  rectum  *.. 

Amis  — — — 


Sphincter  iridis 

Ciliarit 
^^  Rectus  int.,  levator  palpehr,  8up, 

Rectus  inf.  and  sup. 
"•■^'Obl.  infer. 

Obi.  super. 

Masseter,  temporal,  pterygoids 

Rectus  extern. 

Occipitofront.,  orbicularis  oculi  iupperfacial\ 

Muscles  of  expression  {lower  facial) 

Palatal  and  pharyngeal  muscles 

Muscles  of  the  larynx 

Muscles  of  the  tongue 

Sternomastoid 

Deep  muscles  of  the  neck 

Sca'eni 

Trapezius,  terratus    nticu^ 

Diaphragm 

Delt.,  biceps,  pectoral,  maj.  {clavie,  portion)  1  ^ 

Brachial,  antic,  supinator  longus  >  2 

7Viceps,latis.dorsi,pect.  maj.  (costal    *'     ))3 

Extensores  carpi  et  digitorum  ■» 

Flexores  carpi  et  digitorum    J  ^o^'<'"^ 

Interossei,  lumbricales "» 

Thenar,  hypothenar    ) 

Intereoitala 
Muscles  of  the  back 
Abdominal  musclet 


—  Iliopsoas    "V 

Sartorius    I 

Adductors  C  "*''"* 

Abductors  ) 

Quadriceps  \ 

Flexors        V  Leg 

Extensors    j 
,..—  Peronei 

Flexors,  extensors  of  the  foot  and  toe* 

Glutei  (f) 


Perineal  f 

Vesical    >  Musculature 

Rectal     ) 


Fig.  113. — Explanation  of  abbreviations:  tr.  olf.,  olfactory  tract;  c.  g.  I.,  lateral 
geniculate  body;  p,  r,  cr,  A,  indicate  approximately  the  location  of  the  reflex  centers 
for  the  pupillary  (p),  the  respiratory  (r),  cremasteric  {cr),  patellar  (pat),  and  tendo- 
Achilles  (A)  reflexes.  The  vesical  center  lies  in  the  third  and  fourth  sacral  segments; 
the  anal  center  in  the  fourth  and  fifth  (represented  by  circles) ;  the  centers  for  erection, 
ejaculation,  labor  pains  (?)  are  probably  also  situated  in  this  region.  In  reality,  the 
divisions  between  the  various  segments  are,  of  course,  not  so  sharp  as  they  are  shown 
in  the  diagram,  so  that  a  given  muscle  or  cutaneous  region  derives  some  of  its  con- 
trolling nerve  roots  from  the  segments  lying  immediately  above  and  below  the 
principal  segment.  The  sensory  segment  for  any  given  region  is  regularly  somewhat 
higher  than  the  corresponding  motor  segment.     (Gray.) 


270    SOME  ANATOMICAL  AND  PHYSIOLOGICAL  REMINDERS 


Radices  dor  salts  /+/If 
Hadices  cervicale. 
Posterior  Root  Zom 


Radices  dor  sales  V+XII 
I  Radices  lumbares 

J  sacrales  ^^Oval  Field 

Descending  dorsal  root  fibers 
-Marginal  Zone 

ractus  corticospinalia 


cerebello  spinalis 
posterior 


Limiting  Layer- 


Tractus  cortico 
spinalis  cruciatus] 


Tractus  cerebello' 
spinalis  anterior 


Fibrae  associativae  breves 

Fibrae  associativae  longae 


Fasciculus  longitudinalis  dorsalia 


Fig.  114. — Cross-section  of  spinal  cord,  showing  localization  of  chief  structures  with 
lesions.     (Jelliife  and  White.) 


Location  of  Lesion. 
1.  In  the  posterior  root  zone. 


2.  In  posterior  column  of  one  side. 

3.  In  Goll's  columns  of  both  sides. 


4.  In  central  gray,  especially  of  anterior 

commissure. 

5.  Posterior  portion  of  the  lateral  columns 

with  integrity  of  limiting  layer. 

6.  Pyramidal  tracts. 


7.  Anterior  horns. 

8.  Spinocerebellar  paths. 

9.  Lateral  recess. 


Chief  Symptoms. 

Irritation  causes  hyperesthesise.  Destruc- 
tion causes  loss  of  superficial  sensibility 
in  the  root  distribution  spreading  over 
at  least  three  roots.  Ataxia  and  event- 
ually astereognosis  in  the  extremity 
involved. 

Anesthesia  to  deep  sensibility  and  to 
touch.  Ataxia  of  metameres  below  the 
lesion. 

Anesthesia  to  deep  sensibility  and  hypes- 
thesia  of  the  lower  extremities  only, 
even    in    high    lesions. 

Dissociated  sensibility  (thermanesthesia 
and  analgesia  in  the  affected  metameres 
as  indicated  in  the  skin  distribution). 

Crossed  hemihypesthesia  plus  the  symp- 
toms of  6. 

Spastic  paralysis  of  the  caudal  metameres 
below  the  lesion  without  reaction  of 
degeneration,  often  crossed  movements, 
no  atrophy  and  with  increased  reflexes. 

Flaccid  paralysis  of  the  muscles  of  a  num- 
ber of  root  zones,  atonia  and  atrophy 
of  muscles  of  involved  metameres;  R.D., 
loss  of  reflexes. 

Bilateral  involvement  causes  cerebellar 
ataxia. 

Sympathetic  disturbances  metamerically 
distributed. 


The  study  of  the  nervous  system  in  poliomyehtis  has  largely  been 
limited  to  the  motor  neurons,  owing  to  the  fact  that  the  symptoms 
are  so  forcibly  impressed  upon  the  observer.  The  sensory  side  ,is 
worthy  of  study,  even  if  not  so  important  or  the  changes  so  per- 
manent. 


SOME  ANATOMICAL  AND  PIIYSIOLOCICAL  REMINDERS  271 


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trochlear 


%* 


l7if.  Hce^norrhoidal 
of  Pudic 

Superficial  Perineal  of\ 

Pmlic  and  Inferior    I 

Pudendal  of  small     I 

Sciatic  ^ 


:ofSmaas'ci 


Fig.  115. — The  distribution  of  sensory  nerves  in  the'skin.  The  areas  of  the  skin 
supplied  by  the  cutaneous  nerves  are  shown  in  finely|dotted  outline.  The  circles 
on  the  trunk  show  areas  occasionally  anesthetic  in  hysteria.  The  lines  across  the 
limbs  at  ankle,  knee  and  thigh,  wrist,  elbow  and  shoulder  show  the  upper  limits  of 
anesthesia  in  multiple  neuiitis  of  varying  degrees  of  severity.     (After  Flower.) 


Ci 


Cii 


Dvr 


Dx 


Lv 


Areas  of  Anaesthesia  upon  the   Body  after  Lesions  in  the  Various 
Segments  of  the  Spinal  Cord. 

The  segments  of  the  cord  are  numbered:  C  I  to  VIII,  D  I  to  XII,  L  I  to  V.  S  1  to  5, 
and  these  numbers  are  placed  on  the  region  of  the  skin  supplied  by  the  sensory  nerves  of 
the  corresponding  segment. 


XII! 


The  Cervical  and  Sacral  Enlargements  of  the  Spinal  Cord  in  Cross-section. 

(Starr.) 

Showing  the  various  neurons  in  the  gray  matter,  the  direction  of  their  axons,  and  the 
varieties  of  fibers  in  the  different  columns  of  the  cord.  Blue,  motor  neurons  ;  red,  sensory 
neurons  ;  purple,  association  neurons  and  axons. 

I.  Ant.  median  column.  II.  Anterolateral  column.  III.  Gowers'  anterolateral  ascending  column. 
IV.  Marginal  cohmin.  V.  Lateral  pyramidal  column.  VI.  Direct  cerebellar  column.  VII.  Lissauer's 
tract.  VIII.  Ext.  portion  of  column  of  Burdach.  IX.  Root  zone  of  the  column  of  Eurdach.  X. 
Descending  comma-shaped  bundle  of  Schultze.  XI.  Post,  commissural  tract.  XII.  Column  of  Goli 
XIII.   Septomarginal  tract. 


SOME  ANATOMICAL  AND  PIIYSIOUHIICAL  REMINDERS     27-3 

The  sensory  neuron  starts  in  an  end-organ  in  the  skin  or  any 
other  sensory  nerve-ending.     The  trophic  center  of  the  sensory 


Ventral  aspect.  Dorsal  aspect. 

Fig.  116. — Distribution  of  cutaneous  nerves.     (Gray.) 


fiber  is  the  gangUon  cell  or  the  intervertebral  ganglion  to  which 
it  runs,  and  a  lesion  involving  this   cell  or  the   nerve   below  it 
causes  a  degeneration  of  the  nerve  below  the  lesion,  with  the  excep- 
18 


e»psnvi  H33H 


SOME  ANATOMICAL  AND  PHYSIOLOGICAL  REMINDERS    275 


.5     ^    ^ 


276     SOME  ANATOMICAL  AND  PHYSIOLOGICAL  REMINDERS 

tion  that  the  end-organ  in  the  muscle  has  its  own  trophic  center  and 
does  not  degenerate.  Lesions  above  the  posterior  root  cell  or  involv- 
ing it  degenerate  upward  as  far  as  the  next  nerve  cell  whose  axon 
proceeds  toward  the  brain.  The  neurons  leading  to  the  cerebellum 
are  very  complex.  The  accompanying  figures  from  Starr  and  Gray 
show  the  distribution  of  the  sensory  nerves  on  the  skin,  and  also 
with  relation  to  the  nerves  as  they  leave  the  cord.  If  the  lesion  is 
in  the  segment  of  the  cord  the  areas  of  skin  supplied  are  important, 
and  these  are  shown  in  Fig.  112. 

Whether  or  not  a  paralysis  corresponds  to  a  peripheral  nerve  or  a 
nerve-root  distribution  is  many  times  important  in  diagnosis,  and 
the  well-known  figures  of  Kocher  are  reproduced.  They  need  no 
explanation. 


CHAPTER   XIX. 

epide:mics. 


Epidemics  of  Poliomyelitis  Prior  to  1911.^ 


Death- 

vFo. 

Year. 

Season. 

Place. 

Cases. 

rate, 
per  cent, 

1 

1841 

Summer 

W.  Feliciana,  La.,  U.  S.  A. 

10 

0 

2 

1843 

Summer 

England 

9 

? 

3 

1868 

June-Aug. 

Norway 

14 

36 

4 

1871- 
1875 

Over  four 
years 

Philadelphia,  Pa.,  U.  S.  A. 

86 

? 

5 

1881 

July 

LTmea,  Sweden 

18 

0 

6 

1883 

June 

Arenzano,  Italy 

5 

40 

7 

1886 

July-Sept. 

Mendal,  Norway 

9 

22 

S 

1886 

June-July 

Ste.  Foye  I'Argentiere,  France 

13 

31 

9 

1887 

May-Nov. 

Stockholm,  Sweden 

44 

7 

10 

1888 

Summer 

Ammeberg,  Sweden 

14 

8 

11 

1889 

June-July 

Thuringia,  Germany 

5 

0 

12 

1893 

Summer 

St.  Girons  (near),  France 

5 

0 

13 

1893 

Boston,  Mass.,  U.  S.  A. 

26 

?     ' 

14 

1894 

Aug.-Sept. 

North  Adams,  Mass.,  U.  S.  A. 

10 

0 

15 

1894 

July-Get. 

Part  of  Vermont,  LT.  S.  A. 

132 

8 

16 

1895 

Aug.-Sept. 

Stockholm,  Sweden 

21 

0 

17 

1895 

May-Sept. 

Revecca,  Italy 

17 

0 

IS 

1895 

June- July 

Montespertoli,  Italy 

7 

0 

19 

1895 

March-April 

Port  Lincoln,  Australia 

14 

0 

20 

1896 

June 

Vails,  Spain 

8 

0 

21 

1896 

July-Aug. 

Greene  County,  Ala.,  U.  S.  A. 

15 

0 

22 

1896 

Summer 

San  Francisco,  Calif.,  U.  S.  A. 

7 

0 

23 

1896 

July 

Cherryfield,  Me.,  U.  S.  A. 

7 

14 

24 

1896 

Summer 

Much  Hadham,  England 

7 

14 

25 

1897 

June 

New  Y'ork  City,  N.  Y.,  U.  S.  A. 

12 

0 

26 

1897 

Summer 

London,  England 

11 

? 

27 

1897 

July-Sept. 

Conegliano,  Italy 

9 

0 

28 

1898 

July-Sept. 

Conegliano,  Italy 

13 

0 

29 

1898 

Summer 

Royersford,  Pa.,  U.  S.  A. 

22 

9 

30 

1898 

Summer 

Norwaj' 

3 

66 

31 

1898 

Summer 

Frankfort,  Germany 

15 

0 

32 

1898 

July-Sept. 

Vienna,  Austria 

42 

0 

33 

1898 

June-Sept. 

Iviel,  Germany 

4 

0 

34 

1899 

Valley  of  Arno,  Italy 

5 

0 

35 

1898 

July-Get. 

Poughkeepsie,  N.  Y.,  U.  S.  A. 

30 

4 

36 

1899 

Summer 

Stockholm,  Sweden 

54 

10 

1  From  the  report  of  the  Health  Department  of  the  City  of  New  Y'ork.  Up  to 
1908  from  the  article  by  Holt  and  Bartlett  (Am.  Jour.  Med.  Sc,  1908,  cxxxv,  647- 
662).     1908  to  1911,  from  Frauenthal  and  Manning  (Infantile  Paralysi.^,  1914). 

A  somewhat  more  complete  list  of  epidemics,  with  information  concerning  them, 
will  be  found  in  the  report  of  the  epidemic  of  1916  in  New  Y'ork  City,  published  by 
the  Department  of  Health  of  the  City  of  New  Y'ork. 


278 


EPIDEMICS 


No. 

37 
38 
39 
40 
41 
42 
43 
44 
45 
46 
47 
48 
49 
60 
51 
52 
53 
54 
55 
56 
57 
58 
59 
60 
61 
62 
63 
64 
65 
66 
-  67 
68 
69 
70 

71 

72 
73 
74 

75 
76 
77 
78 
79 
80 
81 
82 
83 
84 
85 

86 
87 
88 
89 
90 

91 


Year. 

1899 
1899 
1899 
1900 
1901 
1902 
1903 
1903 
1903 
1904 
1904 
1904 
1905 
1905 
1905 
1905 
1905 
1905 
1906 
1906 
1907 
1907 
1907 
1907 
1907 
1907 
1907 
1907 
1907 
1908 
1908 
1908 
1908 
1908 

1908 
1908 
1908 
1908 

1908 
1908 
1908 
1908 
1908 
1909 
1909 
1909 
1909 
1909 
1909 

1909 
1909 
1909 
1909 
1909 

1909 


Season. 

June-Aug. 

June-Nov. 

June- July 

June-Sept. 

May-June 

Summer 

Mar.-Sept. 

Summer 

Summer 

Summer 

Summer 

March-April 

March-April 

July-Sept. 

July-Sept. 

Summer 

Summer 

Summer 

Summer 

Summer 

Summer 

Summer 

Summer 

Summer 

July-Sept. 

Summer 

Summer 

Aug.-Sept. 

Summer 
July 
Summer 
Principally 

summer 
July-Sept. 
Summer 
Summer 
Summer 

(late) 
Autumn 
July-Oct. 
Summer 
Summer 
June-Sept. 
Aug.-Oct. 
March-Dec. 
Summer 
Summer 
Aug.-Sept. 
Summer  and 

winter 
Summer 
Summer 
July-Aug. 
Summer 
Principally 

summer 


Death- 

Place. 

Cases. 

rate, 
per  cent. 

Le  Grand,  Calif.,  U.  S.  A. 

4 

0 

Bratsburg,  Norway 

64 

3 

Thuringia,  Germany 

5 

0 

Gloucester,  Mass.,  U.  S.  A. 

32 

3 

San  Francisco,  Calif.,  U.  S.  A. 

55 

0 

San  Francisco,  Calif.,  U.  S.  A. 

4 

0 

Parma,  Italy 

26 

0 

Gothenberg,  Sweden 

20 

0 

Norway 

18 

33 

Norway 

61 

20 

Sidney,  Australia 

49 

0 

Brisbane,  Australia 

108 

4 

Queanbergen,  Australia 

6 

? 

Norway 

719 

15 

Sweden 

1,030 

17 

Bavaria,  Germany 

197 

St.  Mary's,  Canada 

17 

6 

Illinois,  U.  S.  A. 

8 

? 

Sweden 

429 

10 

Norway 

466 

10 

Live  Oak,  Fla.,  U.  S.  A. 

16 

? 

Norway 

204 

15 

New  York  City,  N.  Y.,  U.  S.  A. 

2,500 

5 

Massachusetts,  U.  S.  A. 

234 

5 

Oceana  Co.,  Mich.,  U.  S.  A. 

20 

5 

Pennsylvania,  U.  S.  A. 

143 

6 

Paterson,  N.  J.,  U.  S.  A. 

24 

0 

Sweden 

467 

10 

Pennsylvania,  U.  S.  A. 

200 

5 

Sweden 

317 

10 

Heidelberg,  Germany 

36 

10 

Iowa,  U.  S.  A. 

12 

0 

England 

8 

? 

Norway 

59 

10 

Flint,  Mich.,  U.  S.  A. 

30 

17 

Russia 

49 

? 

Whittemore,  Iowa,  U.  S.  A. 

10 

0 

Minnesota,  U.  S.  A. 

150 

9 

Melbourne,  Australia 

135 

4 

Vienna  and  Lower  Austria 

266 

11 

Wisconsin,  U.  S.  A. 

408 

15 

Massachusetts,  U.  S.  A. 

136 

6 

Salem,  Va.,  U.  S.  A. 

25 

0 

Minnesota,  U.  S.  A. 

600 

5 

Nebraska,  U.  S.  A. 

1,037 

13 

Hesse-Nassau,  Germany 

130 

12 

Rhenish  Westphalia,  Germany 

500 

15 

Holland 

38 

11 

Styria,  Austria 

600 

14 

Paris  (and  environs),  France 

41 

10 

Massachusetts,  U.  S.  A. 

923 

8     . 

Santa  Clara  Province,  Cuba 

140 

8 

Petrograd,  Russia 

29 

2 

Norway 

59 

10 

Sweden 


178 


10 


EPIDEMICS 


279 


No. 

Year. 

Season. 

92 

1909- 
1910 

Summer 

93 

1909 

94 

1909 

95 

1909 

96 

1909 

97 

1909 

98 

1910 

Summer 

99 

1910 

June-Nov. 

100 

1910 

May-Sept. 

101 

1910 

May-Sept. 

102 

1910 

103 

1910 

Principally 
summer 

104 

1910 

Summer 

105 

1910 

Sunmier 

106 

1910 

Summer 

107 

1910 

April 

108 

1910 

109 

1910 

110 

1910 

111 

1910 

112 

1910 

113 

1910 

114 

1910 

115 

1910 

116 

1910 

117 

1910 

118 

1910 

119 

1910 

120 

1910 

121 

1910 

122 

1910 

123 

1910 

124 

1910 

125 

1910 

126 

1910 

127 

1910 

128 

1910 

129 

1910 

130 

1910 

131 

1910 

132 

1910 

133 

1910 

134 

1910 

135 

1910 

136 

1910 

137 

1910 

138 

1910 

139 

1910 

140 

1910 

141 

1911 

Oct.-Dec. 

142 

1911 

Oct.-Dec. 

143 

1911 

Oct.-Dec. 

144 

1911 

Sept.-Nov. 

145 

1911 

Summer 

146 

1911 

May-Aug. 

147 

1911 

Summer 

148 

1911 

Summer 

149 

1911 

Summ 

er 

Place. 


Brazil 


Kansas,  U.  S.  A. 

Oregon,  U.  S.  A. 

North  Dakota,  U.  S.  A. 

Montana,  U.  S.  A. 

Indiana,  U.  S.  A. 

Switzerland 

Washington,  D.  C,  U.  S.  A. 

Anjou,  France 

California,  U.  S.  A. 

Sweden 

Norway 

Paris,  France 
Pennsylvania,  U.  S.  A. 
Idaho,  U.  S.  A. 
Iowa,  U.  S.  A. 
Arizona,  U.  S.  A. 
Colorado,  U.  S.  A. 
Connecticut,  U.  S.  A. 
Delaware,  U.  S.  A. 
Florida,  U.  S.  A. 
IlUnois,  U.  S.  A. 
Indiana,  U.  S.  A. 
Kansas,  U.  S.  A. 
Kentucky,  U.  S.  A. 
Maryland,  U.  S.  A. 
Massachusetts,  U.  S.  A. 
Hillside,  Mich.,  U.  S.  A. 
Minnesota,  U.  S.  A. 
Montana,  U.  S.  A. 
Nebraska,  U.  S.  A. 
Nevada,  U.  S.  A. 
New  Hampshire,  U.  S.  A. 
North  Dakota,  U.  S.  A. 
Ohio,  U.  S.  A. 
Oklahoma,  U.  S.  A. 
Oregon,  U.  S.  A. 
South  Carohna,  U.  S.  A. 
Rhode  Island,  U.  S.  A. 
South  Dakota,  U.  S.  A. 
Utah,  U.  S.  A. 
Vermont,  U.  S.  A. 
Virginia,  U.  S.  A. 
Washington,  U.  S.  A. 
Montreal,  Quebec,  Canada 
Ontario,  Canada 
British  Columbia 
United  States  (as  a  whole) 
Schleswig-Holstein 
California,  U.  S.  A. 
Sweden 

Budapest,  Hungary 
Cincinnati,  Ohio,  U.  S.  A. 
Buenos  Aires,  Argentina 
Poland 
Norway 
England 
Birmingham,  England 


Death- 

rate, 

Cases. 

per  cent. 

13 

0 

100 

55 

11 

75 

25 

4 

14 

25 

9 

506 

3 

18 

5 

139 

7 

180 

10 

32 

10 

Fev/ 

0 

1,076 

22 

76 

20 

654 

24 

30 

168 
8 

19 
137 
500 
198 
3 
300 
843 

72 
1,000 
170 
144 
9 
210 
150 

50 

20 
112 
150 
231 

86 
120 

48 
335 
225 

38 
179 

75 

14,590 

132 

55 
3,840 

150 
39 
166 
1,250 
229 
150 


12 


23 


12 


20 

24 
10 

31 

0 

4 

10 

21 


280 


EPIDEMICS 


The   Prevalence   of   Poliomyelitis   in   the 
Since  1910  Compiled  from  the  Reports  of 
States  Public  Health  Service 


United   States 
the  United 


Death- 

rate, 

Year. 

Season. 

Place. 

Cases. 

per  cent. 

1911 

California 

25 

44.0 

1911 

J  uly-No  vember 

Connecticut 

44 

? 

1911 

District  of  Columbia 

7 

2.9 

1911 

April-December 

Idaho 

13 

7.0 

1911 

July-September 

Illinois 

141 

24.0 

1911 

July-October 

Indiana 

97 

62.0 

1911 

August-December 

Iowa 

68 

50.0 

1911 

June-November 

Massachusetts 

260 

8.9 

1911 

Michigan 

23 

78.0 

1911 

June-August 

Minnesota 

69 

79.0 

1911 

June-November 

New  York 

138 

34.0 

1911 

July-December 

New  York  City 

347 

? 

1911 

North  Dakota 

11 

9.0 

1911 

Pennsylvania 

177 

24.0 

1911 

Rhode  Island 

13 

38.0 

1911 

January-October 

South  Dakota 

26 

30.0 

1911 

March-December 

Vermont 

27 

29.0 

1911 

Virginia 

332 

3.0 

1911 

Washington 

38 

42.0 

1911 

Wisconsin 

56 

42.0 

1912 

Connecticut 

31 

? 

1912 

July-November 

Illinois 

480 

11.0 

1912 

July-November 

Indiana 

92 

44.0 

1912 

September-November 

Iowa 

77 

48.0 

1912 

August-October 

Kansas 

72 

15.0 

1912 

July-October 

Maryland 

32 

50.0 

1912 

July-November 

Massachusetts 

169 

44.0 

1912 

Minnesota 

22 

? 

1912 

New  Jersey 

44 

41.0 

1912 

July-November 

New  York 

1108 

16.0 

1912 

July-November 

Oklahoma 

14 

42.0 

1912 

July-December 

Pennsylvania 

163 

? 

1912 

Virginia 

229 

10.0 

1912 

September-December 

Wisconsin 

54 

38.0 

1913 

California 

90 

36.0 

1913 

Connecticut 

29 

? 

1913 

Idaho 

10 

40.0 

1913 

Illinois 

126 

18.0 

1913 

July-November 

Indiana 

'  104 

36.0 

1913 

July-September 

Iowa 

50 

56.0 

1913 

July-November 

Kansas 

90 

16.0 

1913 

Maryland 

10 

? 

1913 

August-December 

Massachusetts 

362 

? 

1913 

Michigan 

56 

55.0 

1913 

July-September 

Minnesota 

74 

36.0 

1913 

August-November 

New  Jersey 

73 

24.0 

1913 

July-December 

New  York 

482 

25.0 

1913 

July-November 

Virginia 

246 

? 

1913 

Washington 

18 

50.0 

1913 

August-October 

Wisconsin 

74 

33.0 

1914 

California 

56 

46.0 

1914 

Connecticut 

11 

18.0 

1914 

Illinois 

142 

24.0 

1914 

Indiana 

58 

48.0 

EPIDEMICS 

2^ 

Death- 

rate, 

Year. 

Season. 

Place. 

Cases. 

per  cent 

1914 

Iowa 

19 

84.0 

1914 

Jiily-Dcccniber 

Kansas 

25 

52.0 

1914 

Maryland 

12 

•> 

1914 

Michigan 

49 

57.0 

1914 

Minnesota 

19 

68.0 

1914 

Mississippi 

113 

20.0 

1914 

New  Jersey 

32 

? 

1914 

New  York 

224 

31.0 

1914 

Ohio 

63 

? 

1914 

South  Carolina 

21 

? 

1914 

August-October 

Vermont 

301 

17.0 

1914 

August-October 

Washington 

21 

42.0 

1914 

August-November 

Wisconsin 

31 

35.0 

1915 

California 

62 

30.0 

1915 

August-November 

Connecticut 

35 

11.0 

1915 

Indiana 

36 

47.0 

1915 

Kansas 

48 

31.0 

1915 

July-August 

Maryland 

66 

? 

1915 

September-October 

Michigan 

71 

42.0 

1915 

September-No  vem  ber 

Minnesota 

127 

20.0 

1915 

Mississippi 

85 

? 

1915 

. .  • 

New  Jersey 

36 

? 

1915 

New  York 

257 

16.0 

1915 

July-November 

Ohio 

466 

? 

1915 

August-November 

Vermont 

42 

40.0 

1915 

Virginia 

241 

? 

1915 

... 

Washington 

10 

30.0 

1915 

, . 

Wisconsin 

14 

78.0 

Poliomyelitis  in  1916  in  the  United  States.    Public  Health 

Reports  of  the  United  States  Public  Health  Service, 

June  1,  1917. 


Cases 
reported. 

Alabama 186 

Arizona 6 

California 132 

Colorado 16 

Connecticut         ....  951 

District  of  Columbia     .      .  39 

Indiana 207 

Iowa 259 

Kansas 103 

Kentucky 146 

Louisiana 77 

Maine 149 

Maryland 352 

Massachusetts    ....  1,926 

Michigan 616 

Minnesota 909 

Mississippi 269 

Montana 94 

New  Jersey 4,055 

New  York 13,223 


Indicated 

Indicated 

Deaths 

case  rate 

fatality 

Estimated 

regis- 

per 1000 

rate  per 

population 

tered. 

inhabitants. 

100  cases. 

July  1,  19](i 

51 

0.080 

27.42 

2,332,608 

0.023 

255,544 

26 

0.045 

19.70 

2,938,654 

0.017 

962,060 

235 

0.764 

24.71 

1,244,479 

6 

0.107 

15.38 

363,980 

50 

0.073 

24.15 

2,816,817 

51 

0.117 

19.69 

2,220,321 

26 

0.056 

25.24 

1,829,545 

48 

0.061 

32 .  88 

2,379,639 

18 

0.042 

23.38 

1,829,130 

0.193 

772,489 

111 

0.258 

31.53 

1,362,807 

424 

0.518 

22.01 

3,719,156 

138 

0.202 

22.40 

3,054,854 

105 

0.399 

11.55 

2,279,603 

31 

0.138 

11.52 

1,951,674 

26 

0.205 

27.66 

459,494 

1180 

1.376 

29.10 

2,948,017 

3331 

1.287 

25.19 

10,273,375 

282 

EPIDEMICS 

Indicated 

Indie  ated 

Deaths 

case  rate 

fatality 

Estimated 

Cases 

regis- 

per 1000 

rate  per 

population 

reported. 

tered. 

inhabitants. 

100  cases. 

July  1,  1916 

Ohio          546 

0.106 

5,150,356 

Oregon     . 

38 

4 

0.045 

10.53 

835,471 

Pennsylvania 

2,181 

0.256 

8,522,017 

South  Carolina 

123 

36 

0.076 

29.27 

1,625,475 

Texas 

86 

35 

0.019 

40.70 

4,429,566 

Vermont 

64 

12 

0.176 

18.75 

363,699 

Virginia   . 

330 

59 

0.151 

17.88 

2,192,019 

Washington 

30 

7 

0.020 

23.33 

1,534,221 

West  Virginia 

82 

0.059 

1,386,038 

Wisconsin     . 

475 

79 

0.190 

16.63 

2,500,000 

Wyoming 

7 

3 

0.039 

42.86 

179,559 

No  satisfactory  figures  covering  the  past  few  years  for  European 
countries  are  available.  An  account  of  the  prevalence  of  the 
disease  throughout  the  world  in  recent  times  is  given  by  Bruce 
Low.^ 

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51.  Naunestadt:     Norsk.  Mag.  f.  Laegevidensk,  1906,  Ixvii,  409. 

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61.  Lovett:     Massachusetts  State  Board  of  Health,  1908,  p.  756. 

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284  EPIDEMIC^ 

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Correspondence  -ftTth  State  Board  of  Health  of  Wisconsin. 

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80.  Wiley  and  Darden:     Jour.  Am.  Med.  Assn.,  1909,  Hi,  617. 

81.  Hamilton  and  Hill:     Jour.  Minnesota  Med.  Assn.,  1910,  xxx,  2,  5. 

82.  Armstrong:     1910,  xii,  496. 

Anderson:     Anderson  Pediatrics,  1910,  xxii,  543,  Western  Med.  Rev.,  1910, 

XV,  391. 
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83.  Miiller:     Mimchen.  med.  Wchnschr.,  1909,  Ivi,  2460. 
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84.  Reckzeh:     Med.  Klinik,  1909,  No.  45,  v,  1704. 
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85.  Netter:     Bull,  et  mem.  de  la  Soc.  med.  de  hop.  de  Paris,  1909,  xxviii,  554,  746. 

86.  Reckzeh:     Med.  lOin.,  No.  45,  v,  1704. 

Krause:     Deutsch.  med.  Wchnschr.,  1909,  xxxv,  1825. 
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87.  Bull,  de  I'Acad.  de  med.,  1910,  Ixiii,  458. 

88.  Lovett  and  others:     Bull.  Massachusetts  State  Board  of  Health,  1910,  n.  s., 
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89.  Lebredo  and  Recio:     Sanidad  y  Beneficia,  1910,  iii,  170. 

90.  Harbitz:     Jour.  Am.  Med.  Assn.,  1912,  lix,  782. 

91.  Harbitz:  Jour.  Am.  Med.  Assn.,  1912,  lix,  782. 

92.  Report  of  the  New  York  Epidemic  of  1916. 

93.  Ferreira:     Bull,  de  la  Soc.  d.  ped.  de  Paris,  1911,  xiii,  370. 

94.  Correspondence  Section  of  State  Board  of  Health. 

95.  Correspondence  Section  of  State  Board  of  Health. 

96.  Correspondence  Section  of  State  Board  of  Health. 

97.  Correspondence  Section  of  State  Board  of  Health. 

98.  Correspondence  Section  of  State  Board  of  Health. 

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102.  Gundrum:     California  State  Jour,  of  Med.,  1913,  xi,  193. 

103.  Report  of  the  New  York  Epidemic  of  1916. 

104.  Harbitz:     Jour.  Am.  Med.  Assn.,  September,  1912. 

105.  Netter:     Bull,  de  I'Acad.  de  med.,  1910,  Ixiii,  458. 

106.  Dixon   and   Karsner:     Am.    Jour.    Dis.    Child.,    1911,   ii,    221.     From   cor- 
respondence with  Pennsylvania  State  Board  of  Health. 

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108.  Frost:     Hyg.  Lab.  Bull.,  No.  90  (United  States  Public  Health  Service). 

109.  Lovett:     Infantile  Paralysis  in  United  States  in  1910. 

110.  Correspondence  Section  of  State  Board  of  Health. 

111.  Lovett: 

112.  Lovett: 

113.  Lovett: 

114.  Frost: 

115.  Lovett: 

116.  Lovett: 

117.  Batte,  John:     Cincinnati. 

118.  Lovett: 

119.  Lovett:     Correspondence  Section  of  Massachusetts  State  Board  of  Health. 

120.  Green,  B.  F.,  of  Hillside: 

121.  Lovett: 


EPIDEMICS  285 

122.  Lovett: 

128.  Correspondence  Section  of  State  Board  of  Health. 

124.  Lovett: 

125.  Lovett: 

126.  Frost: 

127.  Lovett: 

128.  Correspondence  Section  of  State  Board  of  Health. 

129.  Report  of  the  New  York  Epidemic  of  1910. 
1.30.  Bull.  South  Carolina  State  Board  of  Health. 

131.  Frost: 

132.  Lovett: 

133.  Lovett: 

134.  Correspondence  Section  of  State  Board  of  Health. 

135.  Correspondence  Section  of  State  Board  of  Health. 

136.  Correspondence  Section  of  State  Board  of  Health. 

137.  Lovett. 

138.  Russen,  Colin,  Montreal. 

139.  Lovett: 

140.  Lovett: 

141.  Mejrer: 

142.  Gundrum:     California  State  Joui-nal  Med.,  1913,  xi,  193. 

143.  State    Medical    Institute    of    Sweden    Report;    Investigation   on    Epidemic 
Infantile  Paralysis,  1912. 

144.  Frost:     Hyg.  Lab.  Bull.  90,  U.  S.  Public  Health  Service. 

145.  Frost:     Hyg.  Lab.  Bull.  No.  90  (United  States  Public  Health  Ser^^ce). 

146.  Acuna  and  Schweizer:     Rev.  Soc.  nied.  arg.,  1911,  six,  449. 

147.  DeBiehler:     Ai-ch.  de  med.  des  inf.,  1914,  x\'ii,  1. 

148.  Harbitz:     Fifteenth  Internat.  Con.  of  Hyg.  and  Demog.,  1912,  pt.  2,  i,  577. 

149.  Cross:     British  Med.  Jour.,  1912,  i,  721. 

Local  Government  Board,  Great  Britain,  1911-12,  xli,  29. 

Tomkris:     British  Med.  Jovir.,  1912,  i,  182. 

England:     British  Med.  Jour.,  1911,  ii,  1691. 

Roth:     Lancet,  1913,  ii,  1378. 

Gregor  and  Hopper:     British  Med.  Jour.,  1911,  ii,  1154. 

Moss-Blundell:     British  Med.  Jour.,  1911,  ii,  1157. 

Saltan:     British  Med.  Jour.,  1911,  ii,  1151. 

150.  Hiller:     British  Med.  Jour.,  1911,  ii,  1690. 
Moir:     British  Med.  Jour.,  1911,  ii,  1693. 
Jubb:     Lancet,  1915,  i,  67. 


INDEX  OF  AUTHOES. 


See  Also  List  of  References  ix  the  Chapter  on  Epidemics 


Abramson,  42 
Amoss,  30,  41,  42,  168,  172 
Anderson,  29,  87 
Auerbach,  122 


B 

Baas,  20 

Badham,  19,  114,  165 
Banzhaf,  173 
Barlow,  73,  204 
Barthez,  25,  73 
Bartsch,  19 
Batten,  63 
Bergenholz,  28 
Bernard,  Claude,  132 
Bernhardt,  28 
Bouchut,  73 
Bou^■ie^,  26 
Bramwell,  64 
Brown,  48 
Bruck,  19 
Brush,  140 
Bull,  48 
Biilow-Hansen,  28,  47 


Caverly.  28 
Cepelka,  131 
Charcot,  27,  28,  73 
Chassaignac,  26 
Chesnev,  168 
Clark,  176,  254 
Ckrke,  27 
Colmer,  25 
Cook,  189 
Cordier,  28 
Cornil,  26 
Creel,  59 
Crouzon,  163 


Dam-vschino,  27 

Dana,  137 

Demnie.  27 

Dixon,  47 

Dochez,  27,  75,  83,  84,  103,  106,  108, 

116,  131,  132.  159,  175.  264 
Draper.  27,  30,  68.  75.  S3.  84.  103.  106, 

108.  116.  124,  131,  132.  159,  160,  173, 

175.  264 
DuBois.  141 

Duchenne.  25,  28,  64,  73,  81,  162 
Duncan,  175 


ECHEVEREL\,  27 

Emerson,  53,  67 
Erb,  28,  73,  183 
Erlacher,  202 
Eshner,  123 


Feltox,  140 

Fischer,  68 

Flexner.  29.  30.  41.  42.  44,  48,  50,  51, 

69,  167,  172,  173,  254 
Fliess,  26 
Forster,  123 
Foiderton,  47 
Fox,  47 
Freese,  48 
Frost,  29,  87,  264 


Gallie,  200 
Geirsvold,  47 
Gray,  267 
Gule,  73 


288 


INDEX  OF  AUTHORS 


H 

Hall,  Marshall,  18,  73 

Hammers,  140 

Hammond,  28 

Harbitz,  27,  28,  32,  38,  47,  75, 

Havens,  51 

Heine,  20,  21,  25,  26,  73 

Herz,  200 

Herzog,  42,  47 

Higier,  130 

Hoffman,  130 

Hogue,  131 

Holt,  74 

Howland,  74 

Huntemliller,  50 

Hutin,  19,  26 


Jacobi,  27,  264 
Jelliffe,  268 
Joffroy,  27 
Jorg,  19 
Joseph,  29,  50,  167 


K 

Kennedy,  25 
Klein,  26 

Kling,  42,  56,  57,  264 
Kocher,  276 
Kolmer,  48 
Krause,  50,  74,  133 
Kussmaul,  28 


Laborde,  26,  27 
La  Fetra,  87 
Lanceraux,  27 
Landolt,  92,  165 
Landry,  89 

Landsteiner,  29,  41,  50 
Lange,  199,  200 
Leegaard,  28,  122 
Leiden,  27 
Leiner,  29,  50 
Lents,  50 

Levaditi,  29,  41,  50,  56,  57,  167 
Lewis,  29,  41,  42,  50,  51,  69,  167,  176 
Lindner,  157 
Longet,  26 

Lovett,  99,  100,  118,  162,  164,  181,  183, 
196,  201,  202,  204,  247,  249,  250,  264 
Low,  281 
Lucas,  118 


M 


Maccormac,  47 

MacPhail,  28 

Mally,  157 

Marie,  Pierre,  28,  84,  87,  163 

Marks,  51 

Martin,  162,  204,-  247,  249,  250 

Mathers,  47,  48 

Maxcy,  140 

Medin,  26,  28,  32,  38,  52,  80,  81,  85,  88, 

113,  114,  122,  126 
Meinicke,  50 
Meltzer,  166,  175,  176 
Merriman,  18 
Meyer,  28 
Miller,  140 
Mitchell,  17 
Mobius,  87 
Morton,  63 
MuUer,  65,  75,  103,  108,  122,  126 


N 

Neal,  141 

Netter,  29,  88,  167,  168,  172 

Neurath,  87 

Neurot,  123 

Neustaedter,  43,  50,  62,  173 

Nicoladani,  198 

NicoU,  70 

Noguchi,  29,  44,  46,  48,  149 

Nonno,  81 

Nuzum,  42,  47 


Oppenheim,  87 


Parrot,  27 

Pasteur,  47 

Pastia,  41 

Peabody,  27,  75,  83,  84,  103,  106,  108, 

116,  131,  132,  159,  175,  264 
Pettersson,  42,  264 
Pierret,  27 
Popper,  29 
Prevost,  27 


Raymond,  27,  163 
Rilliet,  25,  73 
Rissler,  27,  32,  38,  81 
Roger,  27 


INDEX  OF  AUTHORS 


289 


Rorner,  29,  41,  50,  167 
Rosonau,  51,  59 
Rosenow,  E.  C,  47,  48 
Rucker,  47 


Sachs,  88 

Salaniei',  168 

Scheel,  27,  32,  38,  47,  75,  86 

Schultze,  27,  28 

Schwartz,  123,  168 

Seeligmiiller,  26,  27,  117,  163,  264 

Seguin,  28,  73 

Sever,  119 

Shaw,  19 

Simpson,  59 

Sinkler,  55,  64,  264 

Sophian,  174 

Spieler,  116,  130 

Spitzy,  202 

Starr,  265,  267,  276 

Steindler,  202 

Stoeffel,  202 

Strauss,  27,  29,  32,  39,  137 

Strlimpell,  27,  28,  35,  75,  84,  124 


Tedeschi,  108 
Thro,  43,  62 
Towne,  47,  48 


U 

Underwood,  17,  18,  26,  73 


VizioLi,  84 

Vogt,  28 

von  Heine,  Bernard,  21 

von  Heine,  Georg,  20 

von  Heine,  Jacob.     {See  Heine.) 

von  Heine,  Karl,  21 

von  Recklinghausen,  26 

von  Reinicker,  26 

von  Wiesner,  29,  41,  50 

Vulpian,  27,  73 

Vulpius,  264 


W 


Wernstedt,  42,  264 

West,  25,  73,  93 

Wheeler,  47,  48 

White,  268 

Whitman,  200,  201 

Wickman,  27,  28,  32,  38,  52,  55,  56,  57, 
60,  74,  76,  78,  83,  87,  88,  108,  113, 
114,  116,  122,  126,  129,  130,  157,  264 

Wiener,  41 

Wright,  204 


Zappert,  74,  84,  116,  157 


19 


GENERAL    INDEX. 


A 


Abdominal  paralysis,  treatment  of,  198 

Abducens,  108 

Abortive  form,  74,  76 

Accuracy  of  diagnosis,  146 

Acidosis,  80,  147 

Acute  fatty  atrophic  paralysis,  73 

infantile  paralysis,  73 

spinal  paralysis,  73 
Adenoids,  67 
Adrenalin  treatment,  175 
Adults,  28 
Age,  63 

and  mortality,  158 
Albumin  test,  139 
Alert  cerebration,  78 
Amaurotic  family  idiocy,  150 
American  death-rates,  158 
Anatomical  reminders,  265 
Anihials,  transmission  to,  49 
Anorexia,  78 

Anterior  poliomyeUtis,  73 
Antipohomyehtis  horse  serum,  173 
Arthrodesis,  201 
Ascending  type,  89 
Astragalectomy,  201 
Ataxia,  transient,  83 
Ataxic  cases,  80 

form,  74 
Athetosis,  85 
Atrophic  paralysis,  73 
Attacks,  second,  123 
Auditory  nerve,  113 
Autotherapy,  175 


B 

Babinski's  reflex,  267 

sign,  88 
Back  muscle  paralysis,  103 
Bacteriology,  47 
Bed-bug,  58 
Bed-sores,  134 
Bedding,  care  of,  259 
Bell's  paralysis,  112,  150 
BibUography,  264 
Blood,  131 


Bones,  changes  in,  38 
Brain,  pathology  of,  35 
Breast-fed  infants,  61 
Bronchitis,  132 
Bronchopneumonia,  147 
Brudzinski's  signs,  79,  145 
Bulbar  form,  74 
paralysis,  115 


Caee  of  bedding,  259 
of  discharges,  259 
of  patient,  259 
of  surroundings,  259 
of  utensils,  259 
Carriers,  passive,  51 

treatment  of,  254 
Cases,  paralysis,  98 

termination  of,  260 
Cell  counts,  cerebrospinal  fluid,  138 
Cerebral  thrombosis,  149 

type,  27,  83 
Cerebration,  alert,  78 
Cerebrospinal  fever,  149 
fluid,  138 

colloidal  gold  test,  reaction  of, 

140 
encephahtic  meningitis,  143 
Fehling's  reaction  in,  143 
Froin's  reaction  in,  143 
macroscopic  appearance  of, 

140 
in  meningismus,  143 
in  poliomyehtis,  141 
meningitis,  149 
Cervicobracliial  plexus,  274 
Chemical  stucUes  of  spinal  fluids,  143 

tests,  139 
Chevne-Stokes  breathing,  113 
Child,  tj'pe  of,  68 
Chorea,  150 

Choroid  plexus  and  the  virus,  42 
Cihospinal  gangha,  108 
Classification,  74 

Holt-Howland,  74 
Ivrause,  74 
Miiller,  75 


292 


GENERAL  INDEX 


Classification,  New  York  Health  De- 
partment, 75 

Peabody,  Draper,  and  Dochez,  75 

Wickman,  74 

Zappert,  74 
Colloidal  gold  reaction,  140 
Conception  of  the  disease,  30 
Condition  after  recovery,  161 
Congenital  spastic  paralysis,  150 
Constipation,  78,  133 
Contact,  59 

Convalescent  stage,  treatment  of,  177 
Convulsions,  126 

epileptic,  83 
Cord,  atrophy  of,  36 
Cranial  nerves,  108 

affection  of,  frequency  of,  114 
Croup,  147 
Cultivation  of  a  micrococci,  47 

of  Noguchi  and  Flexner  organism, 
44 
Cutaneous  nerves,  273 
Cyclic  vomiting,  147 


Day  of  disease  and  death,  160 
Death,  159 

and  day  of  disease,  160 

rates,  American,  158 
foreign,  158 
infant,  72 
Decayed  teeth,  68 
Deformities,  116 

equinus,  treatment  of,  195 

hand,  118 

hyperextension  of  knee,  treatment 
of,  197 

knee,  treatment  of,  196 

knock-knees,  treatment  of,  197 

prevention  of,  179 
Degeneration,  reaction  of,  156 
Delayed  paralysis,  122 
Dehrium,  78,  126 
Dental  paralysis,  73 
Diagnosis,  144 

accuracy  of,  146 

acidosis,  147 

amaurotic  family  idiocy,  150 

Bell's  paralysis,  112,  150 

bronchopneumonia,  147 

cerebral  thrombosis,  149 

cerebrospinal  fever,  149 
meningitis,  149 

chorea,  150 

congenital  spastic  paralysis,  150 

croup,  147 

cychc  vomiting,  147 

diarrhea,  147 

differential,  146 


Diagnosis,  diphtheria,  147 

diphtheritic  paralysis,  151 

electricity  in,  152 

facial  paralysis,  150 

hysteria,  148 

laryngitis,  147 

meningismus,  149 

mental  deficiency,  150 

nephritis,  147 

paralysis,  93 

peripheral  neuritis,  151 

Pott's  disease,  150 

pseudoparalysis,  147 

rabies,  125 

rickets,  148 

scurvy,  147 

spasmophilia,  148 

Tay-Sachs'  disease,  150 

tetany,  148 

transverse  myelitis,  150 

tuberculous  meningitis,  148 

uremia,  147 

vomiting,  cychc,  147 
Diaphragm,  paralysis  of,  104 
Diarrhea,  133,  147 
Differential  count,  138 

diagnosis,  146 
Diphtheria,  147 
Diphtheritic  paralysis,  151 
Diphtheroid  bacilh,  48 
Diplococci,  48 
Discharges,  care  of,  259 
Dislocations,  119 
Distribution,  geographical,  53 

of  paralysis,  98 

of  sensory  nerves  in  the  skin,  272 
Disturbances,  sensory,  129 

of  speech,  126 

of  taste,  126 
Dromedary  group,  30 
Drugs,  treatment  with,  166 
Dry  skin,  130 
Duration  of  serum,  171 
Dust,  60,  62 
Dyspnea,  treatment  of,  165 


Ear,  113 
Education,  72 
Eighth  nerve,  113 
Elbow,  118 
Electricity,  28 

in  diagnosis,  152 

treatment  by,  183 
Eleventh  nerve,  113 
Emotional  states  during  convalescence, 

130 
Encephahtic  form,  74 
Epidemics,  277 


GENERAL  INDEX 


293 


Epidemics,  New  York,  70 
Epidemiology,  history  of,  28,  52 
Epileptic  convulsions,  83 
Epincijhrin  treatment,  175 
Equinus  deformity,  treatment  of,  195 
Eruptions,  130 
Essential  paralysis,  73 

of  children,  73 
Examination  of  muscles,  204 


Facial  nerve,  112 

paralysis,  150 
Fatigue,  180 
Feliling's  test,  143 
Fever,  77 

Fibrillary  twitching,  78,  88 
Fifth  nerve,  109 
First  nerve,  108 
Flea,  58 

Floors,  lower,  67 
Fluid,  cerebrospinal,  138 
Fly,  passive  carrier,  51 
Foam  test,  141 
Food,  60 
Foot,  118 

Foreign  death-rates,  158 
Fourth  nerve,  108,  109 
Frequency,  53 

of  cranial  nerve  afTection,  114 
Fruit,  60 
Froin's  reaction,  143 


G 


Gastro-intestinal  cases,  79 

symptoms,  78 

tract,  132 
General  suggestions  for  prevention,  260 
Geographical  distribution,  53 
GlobuUn  test,  139 
Glossopharyngeal  nerve,  113 
Glycosuria,  132 
Gordon's  reflex,  267 
Gram-negative  baciUi,  48 
Guinea-pig  and  virus,  50 


H 


Headache,  125 

puncture,  137 
Health  department  nurses,  257 
Heart,  132 
Hei-pes,  130 

Hexamethjdenamin,  254 
Hip,  118 

deformities,  treatment  of,  197 


Histological  changes,  34 

history  of,  26,  27 
Holt-Howland  classification,  74 
Hosi)ital,  removal  to,  25() 

visits  of  parents  to,  258 
Hydrotherapy,  181 
Hygienic  conditions,  67 
Hyperextension  of  knee,  197 
Hypoglossal,  114 
Hysteria,  148 


Idiocy,  amaurotic  family,  150 
Idiopatliic  paralysis,  73 
Immune  bodies,  length  of  time  persist- 
ing, 172 
Immunity,  69 

test,  144 
Incubation  period,  122,  255 
Infant  death-rate,  72 
Infantile  paralysis,  73 

spinal  paralysis,  73 
Infection,  intra-uterine,  63 

length  of,  72 
Information  for  the  public,  260 
Insects,  58 

virus  in,  51 
Intercostals,  paralysis  of,  106 
Intra-uterine  infection,  63 
Intravenous  injection  of  serum,  172 
Isolation,  255 


Joint  swelhngs,  130 


Kernig's  sign,  79,  88,  145 
Knee,  118 

deformities  of,  treatment  of,  196 

hyperextension  of,  197 
Knock-knees,  ti-eatment  of,  197 
Krause's  classification,  74 


Landry's  paralysis,  74,  89 

Laryngitis,  147 

Larynx,  113 

Late  cord  affections,  163 

Leukocj'tosis,  131 

Lice,  58 

Liver,  changes  in,  39 

Localization  of  reflexes,  266 

Lower  floors,  67 


294 


GENERAL  INDEX 


Lumbar  puncture,  28,  135 
treatment  by,  166 
Lumbosacral  plexus,  275 
Lymphoid  tissue,  changes  in,  39 


M 


MacEwen's  sign,  79 

Massage,  181 

Measuring  for  orthopedic  apparatus, 

189 
Medulla,  pathology  of,  35 
Mendel's  reflex,  267 
Meningeal  form,  74,  87 
Meningismus,  149 

cerebrospinal  fluids  in,  143 
Meningitis,  cerebrospinal,  149 

tuberculous,  148 
Mental  condition,  77 

deficiency,  150 

degeneration,  85 
Micrococci,  cultivation  of,  47 
Microorganism  causing  poliomyelitis,44 
Milk,  60 
Monkeys,  disease  in,  29 

virus  in,  49 
Moral  deterioration,  85 
Morning  paralysis,  73 
Mortality  and  age,  158 
Mtiller's  classification,  75 
Muscles,  changes  in,  37 

examination  of,  204 

neurotization  of,  202 

test,  spring  balance,  247 

training,  204 
Myelitis  of  the  anterior  horns,  73 

transverse,  150 
Myogenic  paralysis,  73 


N 

Nasal  washings  and  virus,  43 

Nativity,  62 

Neck,  paralysis  of,  103 

Negroes,  62 

Nephritis,  147 

Nerves,  first,  108 

eighth,  113 

eleventh,  113 

fifth,  109 

fourth,  108 

ninth,  113 

second,  108 

seventh,  112 

sixth,  108 

tenth,  113 

third,  108 

transplantation  of,  202 

twelfth,  114 


Neuritis,  peripheral,  151 
Neurotization  of  muscles,  202 
New  York  City  Department  of  Health 
circular,  260 
classification,  75 
epidemic,  70 
Ninth  nerve,  113 

Noguchi  and  Flexner  organism,  cultiva- 
tion of,  44 
Nonparalytic  form,  76 
Normal  horse  serum,  174 

human  serum,  174 
Nose,  67 
Nurse,  259 

health  department,  257 
requirements  for,  257 
Nystagmus,  126 


Ocular  nerve,  108 
Oculomotor  nerve,  108 
Old  cases,  pathology  of,  36 
Olfactory  nerve,  108 
Onset,  76 

mental  condition  in,  77 

pain  in,  77 

of  paralysis,  93 

symptoms  of,  76 

without  prodromata,  122 
Operative  treatment,  195 
summary  of,  202 
Oppenheim's  reflex,  267 
Orthopedic  apparatus,  measuring  for, 
189 

treatment,  185 


Pain,  77,  79,  127 

at  onset,  77 

disappearance  of,  129 

treatment  of,  165 
Pandy's  test,  139 
Paralysis,  abdominal,  treatment  of,  198 

acute  fatty  atrophic,  73 
infantile,  73 
spinal,  73 

atrophic,  73 

back  muscles,  103 

Bell's,  112,  150 

bulbar,  115 

congenital  spastic,  150 

delayed,  122 

dental,  73 

diagnosis  of,  93 

diaphragm,  104 

diphtheritic,  151 

distribution  of,  98 


GENERAL  INDEX 


295 


Paralysis  during  dentition,  73 

essential,  73 

of  cliildrcn,  73 

facial,  150 

{!;astrocnemius,      treatment      of, 
187 

idiopathic,  73 

infantile,  73 
spinal,  73 

intercostals,  106 

morning,  73 

myogenic,  73 

neck,  103 

onset  of,  93 

regressive,  73 

teething,  73 

thoracic,  106 
Paralj-tic  brace,  187 

cases,  95 
Parents,  visits  of,  to  hospitals,  258 
Passive  carriers,  51 
Patheticus,  108 
Pathology,  32 

history  of,  26 
Patient,  care  of,  259 

return  of,  258 
Peabody,  Draper  and  Dochez  classifica- 
tion, 75 
Peripheral  neuritis,  151 
Peyer's  patches,  39 
Physicians,  requirements  for,  257 
Physiological  reminders,  265 
Placards,  256 
Pneumogastric,  113 
Pneumonia,  132 
Poliomyehtis  anterior,  73 
acuta,  73 

epidemics  of,  277 

in  1916,  281 

in     United     States    since    1910, 
280 
Polyneuritic  form,  74,  88 
Pons,  pathology  of,  35 
Posterior  root  lesions,  35 
Pott's  disease,  150 
Preparation  of  serum,  171 
Preparalytic  stage,  76 
Prevention,  253 

of  deformity,  179 

general  suggestions  for,  260 
Prognosis,  157 

Progressive  inuscular  atrophy,  163 
Prophylaxis,  253 
Prostration,  124 
Pseudoneuritis,  88 
Pseudoparalysis,  147 
Ptosis,  109 

Public,  information  for,  260 
Pulihcity,  72 
Puncture  headache,  137 

lumbar,  135 


Q 


Quarantine,  255 
State,  263 


Rabbits,  virus  in,  50 
Rabies,  diagnosis  from,  125 
Race,  62 
Railroads,  61 

Reaction  of  degeneration,  156 
Recovery,  condition  after,  161 
Recurrences,  122 
Reflexes,  126 

Babinski's,  267 

Gordon's,  267 

localization  of,  266 

Mendel's,  267 

Oppenheim's,  267 
Regressive  paralysis,  73 
Relapses,  122 
Reminders,  anatomical,  265 

physiological,  265 
Remission  of  symptoms,  122 
Removal  to  hospital,  256 
Renovation,  257 
Requirements  for  nurses,  257 

for  physicians,  257 
Respiratory  failure,  treatment  of,  165 

symptoms,  132 
Return  of  patients,  258 

of  suspects,  258 
Rickets,  148 


Salads,  60 

Scohosis,  treatment  of,  188 

Scurvy,  147 

Season,  55 

Second  attacks,  123 

nerve,  108 
Segments  of  spinal  cord,  267 
Sensory  disturbances,  129 

nerves,  distribution  of,  in  skin,  272 
Serum,  antipoliomyehtis  horse,  173 

duration  of,  171 

normal  horse,  174 
human,  174 

intravenous  injection  of,  172 

preparation  of,  171 

subcutaneous  injection  of,  172 

therapj^  167 

treatment,  summary  of,  175 
Seventh  nerve,  112 
Sewage,  61 
Sex,  63 
Shortening,  treatment  of,  187 


296 


GENERAL  INDEX 


Shoulder,  118 
Sign,  Babinski's,  88 

Brudzinski's,  79,  145 

Kernig's,  79,  88,  145 

MacEwen's,  79 
Silk  ligaments,  200 
Sixth  nerve,  108 
Skin,  dry,  130 
Social  conditions,  67 
Spasmophilia,  148 
Spastic  paralysis,  congenital,  150 
Special  features,  122 
Speech  disturbances,  126 
Sphincters,  107 
Spinal  accessory,  113 

cord,  pathology  of,  33 
segments  of,  267 

fluids,  characteristics  of,  142 
chemical  studies  of,  143 

form,  74,  97 
Spleen,  changes  in,  39 
Spodiomyehtis,  73 
Spodomyehtis,  73 
Spring-balance  muscle  test,  247 
Stable  fly,  51,  58 
State  quarantine,  263 
Stomoxys  calcitrans,  51,  58 
Streptococci,  48 
Stupor,  124 

Subcutaneous  injection  of  serum,  172 
Superior  oblique,  109 
Surroundings,  care  of,  259 
Suspects,  return  of,  258 
Sweating,  78,  130 
Swelhngs  of  joints,  130 
Symptomatology,  122 
Symptoms  of  onset,  76 

respiratory,  132 
Synonyms,  73 


Tache  cerebrale,  88,  130 

Tachycardia,  113 

Taste  disturbances,  126 

Tay-Sachs'  disease,  150 

Teeth,  68 

Teething  paralysis,  73 

Temperature,  123 

Tenderness,  127 

disappearance  of,  129 
treatment  of,  165 

Tendon  fixation,  200 
shortening,  200 
transplantation,  198 

Tenodesis,  200 

Tenth  nerve,  113 

Tephromyelitis,  73 

Terminal  disinfection,  257 


Termination  of  case,  260 
Test  for  albumin,  139 

chemical,  139 

Fehling's,  143 

foam,  141 

for  globuhn,  139 

immunity,  144 

Pandy's,  139 

spring-balance  muscle,  247 

Tsuchiya's,  139 
Tetany,  148 
Third  nerve,  108 
Throat,  67 

Thrombosis,  cerebral,  149 
Tonsils,  67 
Total  count,  138 
Training  of  muscles,  204 
Transient  ataxia,  83 
Transmission,  56 

to  animals,  49 

experiments,  29 
Transverse  myelitis,  150 
Travel,  260 
Treatment,  164 

of  abdominal  paralysis,  198 

of  acute  stage,  164 

adrenalin  in,  175 

of  carriers,  254 

of  convalescent  stage,  177 

drugs  in,  166 

of  dyspnea,  165 

electricity  in,  183 

epinephrin  in,  175 

of  equinus  deformity,  195 

of  gastrocnemius,  187 

by  heat,  182 

hexamethylenamin  in,  254 

of  hip  deformities,  197 

of       hyperextension      of      knee, 
197 

of  knee  deformities,  196 

of  knock-knees,  197 

by  lumbar  puncture,  166 

by  massage,  181 

operative,  195 

orthopedic,  185 

of  pain,  165 

paralytic  brace  in,  187 

of  respiratory  failure,  165 

of  scoUosis,  188 

serum  therapy  in,  167 

of  shortening,  187 

of  tenderness,  165 
Tremor,  79,  126 
Trigeminal,  109 
Tsuchiya's  test,  139 
Tuberculous  meningitis,  148 
Twelfth  nerve,  114 
Twitching,  126 

fibrillary,  78,  88 
Type  of  child,  68 


GENERAL  INDEX 


207 


Uremia,  147 
Urine,  131 

Utensils,  care  of,  259 


Vasomotor  disturbances,  79 

Vegetables,  60 

Virus  and  artificial  conditions,  40 

in  cerebrospinal  fluid,  41 

choroid  plexus  and,  42 

cultivation  of,  44 

drying  of,  41 

in  guinea-pigs,  50 

in  human  body,  41 

importation  of,  52 

in  insects,  51 

in  monkeys,  49 

nasal  washings  and,  43 


Virus,  nature  of,  40 

neutralization  of,  43 

outside  the  Ijody,  43 

persistence  of,  43 

portal  of  entry  of,  32 

in  raljbits,  50 

reaction  to  antiseptics,  40 
Visits  of  parents  to  hospitals,  258 
Vomiting,  78,  132 

cyUc,  147 


W 

Watercourses,  61 
Wickman's  classification,  74 


Zappert's  classification,  74 


DUE  DATE 

MAY 

93199^ 

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0037542966 


